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1.	Bjerke, Joakim (författare) Gait and postural control after total knee arthroplasty 2014 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract The aim of the thesis was to investigate deficits and compensatory strategies after total knee arthroplasty (TKA) in different conditions during gait and quiet standing. Although TKA is considered the gold standard treatment for end-stage knee osteoarthritis, it is associated with a number of implications. Reduced physical function after osteoarthritis is partly, but apparently not fully, remedied by surgery. The two most common deficits are reduced knee muscle strength and limited range of knee joint motion (ROM), partly due to prosthesis mechanics. Reduced postural control has also been shown shortly after surgery. In spite of sufficient passive knee joint ROM for normal ambulation, gait patterns are characterized by reduced knee flexion. Several factors such as reduced knee muscle strength, reduced proprioception, habitual strategies or fear of movement may be suggested as explanations for difficulties in gait and posture. As an effect, compensatory strategies may result. In order to focus on the implications of TKA, participants had to be less than 65 years of age and healthy, TKA being the only factor different form controls. The same 23 individuals with unilateral TKA ~ 19 months post-operative and 23 controls participated in all studies. 3D whole body kinematics was used to assess gait and posture and electromyography was used to record muscle activity. Isokinetic measurements were used to determine dynamic knee muscle strength. Gait in the frontal and sagittal planes were assessed. The tasks included in the test protocol were negotiation up and down stairs, gait on hard and soft surface, quiet standing with sensory modulation (with and without vision and on soft surface), and single limb stance. Primary outcome variables addressed were: knee and hip joint kinematics in frontal and sagittal planes, upper body inclination, postural sway and relative knee muscle activity as an indicator of relative effort. Background factors used to explain group differences in the primary outcomes were derived from demographics, clinical examination, and questionnaires. Demographic factors were age, body mass index (BMI), and time since surgery. Clinical examinations were conducted for passive knee joint ROM, joint position sense, knee muscle strength, anterior knee joint laxity, and leg length. Questionnaires assessed fear of movement, pain, and knee related function and quality of life. The results showed that knee flexion was reduced during stair descent in both the prosthetic and the contralateral knee in the TKA group compared to controls. Although reduced passive knee joint flexion in the TKA group was sufficient for normal stair descent, it was the only factor identified that explained reduced knee flexion in stair descent. As knee muscle strength was significantly reduced in the TKA group, it is reasonable to suggest that as a contributing factor. Furthermore, the TKA group also displayed increased hip adduction during stair descent, which may indicate both a compensatory strategy as well as reduced hip muscle strength. In stair ascent, no significant group differences were found in relative knee muscle activity as expected due to knee muscle weakness. Nor were there any indications of compensatory forward inclination of the trunk to reduce knee joint moments. Instead, probably compensating for muscle weakness, the TKA group ascended stairs at a significantly slower speed. Surface modulation during level gait showed that reduced knee flexion in the prosthetic knee during the stance phase when walking on a hard surface was further decreased during gait on a soft surface. Knee and hip adduction at the stance phase were not affected by surface conditions. Nevertheless, the TKA group displayed increased knee adduction and hip adduction compared to controls, particularly in the prosthetic side. In addition, the TKA group displayed increased step width on the soft compared to hard surface. Single-limb stance for 20 seconds failed in 30 % of the TKA group and in 4 % of the control group. Those in the TKA group who were able to perform single-limb stance performed equally well as controls. During bilateral quiet standing, postural sway was similar in both groups, and inability to stand on one leg did not affect bilateral stance. Older age, higher BMI and reduced quadriceps strength determined the failure to maintain single-limb stance in the TKA group. In conclusion, this thesis indicates that reduced knee muscle strength is a common denominator as part of the explanatory factors for reduced performance and compensatory strategies in individuals with TKA. Reduced speed during stair ascent as well as reduced knee flexion during stair descent may be compensations for reduced lower extremity strength. Increased hip adduction may compensate for reduced knee flexion in stair descent, but may also represent hip muscle weakness or reduced motor control as increased hip adduction is found also in level gait. The failure to maintain single-limb stance in the TKA group is also partly explained by reduced knee muscle strength. Muscle weakness may be and indicator for reduced physical capacity in general.
2.	Broström, Anders, et al. (författare) A mixed method evaluation of a group-based educational programme for CPAP use in patients with obstructive sleep apnea 2013 Ingår i: Journal of Evaluation In Clinical Practice. - : Wiley. - 1356-1294 .- 1365-2753. ; 19:1, s. 173-184 Tidskriftsartikel (refereegranskat)abstract Rationale, aims and objectives Continuous positive airway pressure (CPAP) treatment of obstructive sleep apnea (OSA) has a low long-term adherence. Educational interventions are few and sparsely described regarding content, pedagogical approach and participants' perceptions. The aim was to describe adherence to CPAP treatment, knowledge about OSA/CPAP, as well as OSA patients' perceptions of participating in a group-based programme using problem-based learning (PBL) for CPAP initiation.Educational programme The PBL programme incorporated elements from theories and models concerning motivation and habits. Tutorial groups consisting of four to eight patients met at six sessions during 6 months.Methods A sequential explanatory mixed method design was used on 25 strategically selected patients. Quantitative data regarding, clinical variables, OSA severity, CPAP use, and knowledge were collected at baseline, after 2 weeks and 6 months. Qualitative data regarding patients' perceptions of participation were collected after 6 months by semi-structured interviews using a phenomenographic approach.Results 72% of the patients were adherent to CPAP treatment after 2 weeks and 6 months. All patients improved their baseline knowledge about OSA and CPAP after 2 weeks and sustained it after 6 months. Anxiety and fear, as well as difficulties and needs were motivational factors for participation. Patients described the difficulties of behavioural change, an awareness that improvements do not occur immediately, a realization of the importance of both technical and emotional support and the need for a healthier lifestyle.Conclusion and practice implications A group-based programme using PBL seems to facilitate adaptive and developmental learning and result in acceptable CPAP adherence levels.
3.	Broström, Anders, et al. (författare) Do cardiovascular signs and risk factors differ between hypertensive men and women with high versus low risk on the Berlin sleep apnoea questionnaire in a primary care setting? in JOURNAL OF SLEEP RESEARCH, vol 21, issue SI, pp 230-231 2012 Ingår i: JOURNAL OF SLEEP RESEARCH. - : Wiley-Blackwell. ; , s. 230-231 Konferensbidrag (refereegranskat)abstract n/a
4.	Broström, Anders, et al. (författare) Effects of a group-based educational programme on adherence to CPAP treatment in obstructive sleep apnoea in JOURNAL OF SLEEP RESEARCH, vol 21, issue SI, pp 348-348 2012 Ingår i: JOURNAL OF SLEEP RESEARCH. - : Wiley-Blackwell. ; , s. 348-348 Konferensbidrag (refereegranskat)abstract n/a
5.	Broström, Anders, et al. (författare) Factors associated with undiagnosed obstructive sleep apnoea in hypertensive primary care patients 2012 Ingår i: Scandinavian Journal of Primary Health Care. - : Informa Healthcare. - 0281-3432 .- 1502-7724. ; 30:2, s. 107-113 Tidskriftsartikel (refereegranskat)abstract Objective. In hypertensive primary care patients below 65 years of age, (i) to describe the occurrence of undiagnosed obstructive sleep apnoea (OSA), and (ii) to identify the determinants of moderate/severe OSA. Design. Cross-sectional. Setting. Four primary care health centres in Sweden. Patients. 411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed and treated hypertension (BP andgt; 140/90). Main outcome measures. Occurrence of OSA as measured by the apnoea hypopnoea index (AHI). Results. Mild (AHI 5-14.9/h) and moderate/severe (AHI andgt; 15/h) OSA were seen among 29% and 30% of the patients, respectively. Comparing those without OSA with those with mild or moderate/severe OSA, no differences were found in blood pressure, pharmacological treatment (anti-hypertensive, anti-depressive, and hypnotics), sleep, insomnia symptoms, daytime sleepiness, or depressive symptoms. Obesity (BMI andgt; 30 kg/m(2)) was seen in 30% and 68% of the patients with mild and moderate/severe OSA, respectively. Male gender, BMI andgt; 30 kg/m(2), snoring, witnessed apnoeas, and sleep duration andgt; 8 hours were determinants of obstructive sleep apnoea. Conclusion. Previously undiagnosed OSA is common among patients with hypertension in primary care. Obesity, snoring, witnessed apnoeas, long sleep duration, and male gender were the best predictors of OSA, even in the absence of daytime sleepiness and depressive symptoms.
6.	Broström, Anders, 1963-, et al. (författare) Gender differences in respiratory disturbance, sleep and daytime sleepiness in hypertensive patients with different degrees of obesity 2013 Ingår i: European Journal of Cardiovascular Nursing. - : Oxford University Press. - 1474-5151 .- 1873-1953. ; 12:2, s. 140-149 Tidskriftsartikel (refereegranskat)abstract BackgroundHypertension (HT) and obesity have both been linked to obstructive sleep apnoea (OSA). Difficulties have been described in identifying patients with OSA in primary care, causing low referral rates to sleep clinics. Increased knowledge about gender-specific characteristics and symptoms may help to identify patients.AimThe aim was to describe gender differences regarding undiagnosed OSA, self-rated sleep, insomnia and daytime sleepiness in middle-aged primary care patients with HT and different degrees of obesity.MethodsA cross-sectional design was used and 394 patients (52.5% women), mean age 57.8 years (SD 6.7 years), with HT (BP >140/90 mmHg) were included. Clinical examinations, respiratory recordings and self-rated scales regarding OSA symptoms, sleep, insomnia and daytime sleepiness were used. Body mass index (BMI) was classified according to the criteria from the National Institutes of Health.ResultsPre-obesity and obesity classes I and II were seen among 53%, 26% and 8% of the men and 37%, 19% and 14% of the women, respectively. Occurrence of mild, moderate and severe OSA increased significantly across the BMI classes for both genders (p<0.01). Ninety percent of the men and 80% of the women in obesity class II had OSA. Insomnia was prevalent in obese patients. Other clinical variables did not differ between BMI classes or genders.ConclusionThe occurrence of overweight/obesity and OSA was high among both genders. A high BMI might be a convenient clinical marker for healthcare personnel to identify hypertensive patients with possible OSA in need of further evaluation and treatment.
7.	Broström, Anders, et al. (författare) Putative facilitators and barriers for adherence to CPAP treatment in patients with obstructive sleep apnea syndrome: A qualitative content analysis 2010 Ingår i: SLEEP MEDICINE. - : Elsevier BV. - 1389-9457 .- 1878-5506. ; 11:2, s. 126-130 Tidskriftsartikel (refereegranskat)abstract Introduction: Effective treatment of obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) can reduce morbidity and mortality, but adherence rates are low without a clear consensus Of causes. Objective: To explore the experiences of adherence to CPAP treatment in patients with OSAS. Methods: A qualitative content analysis was employed. Data were collected by in-depth interviews with 23 purposively selected patients. Results: Adherence to CPAP treatment was summarized according to "facilitators" and "barriers" to CPAP treatment. Facilitators for adherence, as described by the patients were a desire to avoid symptoms, knowledge about the risk for medical consequences, fear of negative social consequences and disturbing the sleep of significant others. Other facilitators were a positive attitude to CPAP treatment, trust in healthcare personnel, a sense of engagement from the spouse and a feeling of physical improvement. Barriers included experiencing practical problems, negative psychological effects of the equipment, and negative attitudes to the treatment. Other barriers were side-effects as well as insufficient support from healthcare personnel and the spouse. Conclusion: Adherence to CPAP treatment is a multifaceted problem including patient, treatment, condition, social and healthcare related factors. Knowledge about facilitators and barriers for adherence to CPAP treatment can be used in interventional Strategies.
8.	Broström, Anders, 1963-, et al. (författare) Symptom profile of undiagnosed obstructive sleep apnoea in hypertensive outpatients in primary care : a structural equation model analysis 2012 Ingår i: Quality in Primary Care. - London, United Kingdom : iMedPub Ltd.. - 1479-1072 .- 1479-1064. ; 20:4, s. 287-298 Tidskriftsartikel (refereegranskat)abstract BackgroundObstructive sleep apnoea (OSA) has been linked to hypertension in sleep clinic populations, but little is known about the symptom profile of undiagnosed OSA in hypertensive outpatients in primary care.AimTo explore characteristics associated with undiagnosed OSA in hypertensive primary care patients.MethodsCross-sectional design, including 411 consecutive patients (52% women), mean age 57.9 years (standard deviation [SD] 5.9 years), with diagnosed hypertension (blood pressure >140/90 mmHg) fromfour primary care centres. All subjects underwent a full-night, home-based, respiratory recording to establish the presence and severity of OSA. Clinical variables, medication and comorbidities, as well as data from self-rating scales regarding symptoms/characteristics, insomnia, excessive daytime sleepiness, depressive symptoms and health were collected during a clinical examination. Factor analyses and structural equation modelling (SEM) were used to explore the relationships between selfrated symptoms, clinical characteristics and objectively verified diagnosis of OSA.Main outcomeMeasures symptom profile of undiagnosed OSA (as measured by the Apnoea/ Hypopnoea Index [AHI]) in hypertensive outpatients in primary care.ResultsFifty-nine percent of the patients had an AHI _ 5/hour indicating OSA. An exploratory factor analysis based on 19 variables yielded a six-factor model (anthropometrics, blood pressure, OSA-related symptoms, comorbidity, health complaints and physical activity) explaining 58% of the variance. SEM analyses showed strong significant associations between anthropometrics (body mass index, neck circumference, waist circumference) (0.45), OSA-related symptoms (snoring, witnessed apnoeas, dry mouth) (0.47) and AHI. No direct effects of OSA on comorbidities, blood pressure, dyssomnia or self-rated health were observed.ConclusionOSA was highly prevalent and was directly associated with anthropometrics and OSArelated symptoms (snoring, witnessed apnoeas and dry mouth in the morning). When meeting patients with hypertension, these characteristics could be used by general practitioners to identify patients who are in need of referral to a sleep clinic for OSA evaluation.
9.	Broström, Anders, et al. (författare) Symptoms among hypertensive patients with undiagnosed obstructive sleep apnoea in primary care - a structural equation model analysis in JOURNAL OF SLEEP RESEARCH, vol 21, issue SI, pp 230-230 2012 Ingår i: JOURNAL OF SLEEP RESEARCH. - : Wiley-Blackwell. ; , s. 230-230 Konferensbidrag (refereegranskat)abstract n/a
10.	Broström, Anders, et al. (författare) The attitudes to CPAP treatment inventory: development and initial validation of a new tool for measuring attitudes to CPAP treatment 2011 Ingår i: Journal of Sleep Research. - : Blackwell Publishing Ltd. - 0962-1105 .- 1365-2869. ; 20:3, s. 460-471 Tidskriftsartikel (refereegranskat)abstract ontinuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but low adherence rates are common. The aim was to develop the attitudes to CPAP treatment inventory (ACTI), and to investigate the validity and reliability of the instrument among patients with OSAS. ACTI was developed on the basis of: (i) in-depth interviews with 23 patients; (ii) examination of the scientific literature; and (iii) consensus agreement of a multi-professional expert panel. This yielded five different types of attitudes to CPAP treatment. A prospective longitudinal design was used. Two-hundred and eighty-nine patients with OSAS were recruited at three different CPAP centres. Data were collected with ACTI and obtained from medical records. The homogeneity and internal consistency reliability were satisfactorily reflected by the item-total correlations (0.59-0.81) and Cronbachs alpha (0.89), respectively. Construct validity was confirmed with factor analysis (principal component analysis with orthogonal rotation; PCF). The PCF based on baseline data resulted in a one single-factor solution explaining 69% of the total variance. A confirmatory factor analysis was performed 2 weeks after CPAP initiation, resulting in the same factor solution. No indication of uniform differential item functioning was found. The predictive validity was tested with receiver operating characteristic analyses, and a cut-off of 10 on the ACTI gave a sensitivity of 93% and a specificity of 44% for CPAP termination within 6 months. The satisfactory measurement properties of this new pragmatic instrument are promising and indicate that ACTI can be useful in clinical practice to reliably measure attitudes to CPAP treatment.
11.	Broström, Anders, et al. (författare) The side-effects to CPAP treatment inventory : the development and initial validation of a new tool for the measurement of side-effects to CPAP treatment. 2010 Ingår i: Journal of Sleep Research. - : Wiley. - 0962-1105 .- 1365-2869. ; 19:4, s. 603-611 Tidskriftsartikel (refereegranskat)abstract Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea syndrome (OSAS), but side-effects are common. No validated self-rating scale measuring side-effects to CPAP treatment exists today. The aim was to develop the side-effects to CPAP treatment inventory (SECI), and investigate the validity and reliability of the instrument among patients with OSAS. SECI was developed on the basis of: (1) in-depth interviews with 23 patients; (2) examination of the scientific literature and (3) consensus agreement of a multi-professional expert panel. This yielded 15 different types of side-effects related to CPAP treatment. Each side-effect has three sub-questions (scales): perceived frequency (a) and magnitude (b) of the side-effect, as well as its perceived impact on CPAP use (c). A cross-sectional descriptive design was used. A total of 329 patients with OSAS with an average use of CPAP treatment for 39 months (2 weeks to 182 months) were recruited. Data were collected with SECI, and obtained from medical records (clinical variables and data related to CPAP treatment). Construct validity was confirmed with factor analysis (principal component analysis with orthogonal rotation). A logical two-factor solution, the device subscale and symptom subscale, emerged across all three scales. The symptom subscale describing physical and psychological side-effects and the device subscale described mask and device-related side-effects. Internal consistency reliability of the three scales was good (Cronbach's α = 0.74-0.86) and acceptable for the subscales (Cronbach's α = 0.62-0.86). The satisfactory measurement properties of this new instrument are promising and indicate that SECI can be used to measure side-effects to CPAP treatment.
12.	Broström, Anders, 1963-, et al. (författare) Undiagnosed obstructive sleep apnea in hypertensive outpatients in primary care : Associations with sleep complaints, depressive symptoms and global perceived health 2013 Ingår i: Open Journal of Nursing. - : Scientific Research Publishing, Inc.. - 2162-5336 .- 2162-5344. ; 3:6, s. 445-452 Tidskriftsartikel (refereegranskat)abstract Objective: 1) To describe the prevalence of undiagnosed obstructive sleep apnea (OSA) and depressive symptoms in hypertensive men and women below 65 years of age, and 2) to describe the association of OSA to subjective sleep complaints, depressive symptoms and global perceived health. Design: Cross-sectional design focusing on nursing care outcomes of obstructive sleep apnea. Setting: Four primary care health centres in Sweden. PATIENTS: 411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed hypertension (BP > 140/90). Main Outcome Measures: Prevalence of OSA and depressive symptoms, and association of OSA to sleep complaints, depressive symptoms and global perceived health. RESULTS: Mild, moderate and severe OSA was seen among 29%, 16% and 14% of patients, respectively. Depressive symptoms were seen in 16% of the total group, with a higher prevalence among men, compared to women, 21% vs. 12%. No differences were found regarding blood pressure, estimated sleep need, sleep sufficiency index, insomnia symptoms, daytime sleepiness or depressive symptoms with respect to different degrees of OSA. Apnea-hypopnea index was significantly associated to perceived health after adjustment for gender and comorbidities, but when depressive symptoms and non-restorative sleep were added to the model, 33% of the variance in global perceived health was explained. Conclusion: OSA is highly prevalent among patients with hypertension in primary care and does together with sleep complaints and depressive symptoms have a negative impact on global perceived health. Hypertensive patients without subjective sleep complaints or depressive symptoms may still have OSA.
13.	Broström, Eva Berggren (författare) Bronchopulmonary dysplasia from newborn disease to long-term sequelae 2010 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Bronchopulmonary Dysplasia (BPD) is a complication of premature birth that is associated with increased mortality and morbidity in infancy and impaired lung function and obstructive lung disease from childhood to adulthood. The pathogenesis of BPD is multifactorial, and may involve one or more of the following: a deficiency in surfactant production in the immature lung, chronic inflammatory processes before and after birth, oxidative stress, and trauma due to mechanical ventilation. Surfactant replacement therapy, which reduces acute lung injury in the preterm infant, could be one way to prevent later development of BPD. So far, surfactant therapy requires invasive intubation that may itself be traumatic. In this thesis, we evaluated an alternative, non-invasive way to deliver surfactant. This trial of surfactant inhalation via nasal CPAP in spontaneously breathing infants unfortunately did not prove beneficial. Pre- and postnatal inflammatory processes may initiate and aggravate the course of BPD. Some of the underlying inflammatory processes e.g. activation of the neutrophil and macrophage systems, have been well described but other processes, such as the role of eosinophils and other inflammatory markers in the pathology of BPD, have not yet been well characterised. This thesis shows that levels of activated eosinophils in the circulation are elevated in infants with BPD, a sign of chronic, systemic inflammation. We also found that the degree of eosinophil activation was positively associated with the severity of BPD (as determined by the duration of supplementary O2 treatment). Future studies may establish whether a causal relationship exists between states of eosinophil activation in preterm infants and BPD. Moderate and severe BPD is associated with an increased risk for airway obstruction and low forced expiratory volume in childhood. As shown herein, respiratory mechanics is also altered in children with mild BPD. This finding is important because it emphasizes the need for careful clinical follow up of all BPD children, regardless of the severity of the disease, in order to minimize further deterioration in lung function. BPD not only affects lung function but general development as well; thoseffected may develop cognitive and motor performance deficits and exhibit behavioural difficulties. This thesis also sheds new light on public health consequences of very preterm birth. We know little about the possible long-term consequences of premature birth for lung function in old age. In a unique birth cohort born in 1925-49 in Sweden, we found that moderate to-very preterm birth is associated with obstructive lung disease in old age, the severity of which required frequent hospitalisation. The results from this historic cohort cannot be directly extrapolated to preterm infants born today. However, the much higher survival rate in the modern era of neonatal intensive care suggests that infants born preterm nowadays could be at even higher risk of developing obstructive airways disease in adult life than were previous generations. This finding emphasizes the importance of extending follow up programs into adult life. Preterm birth is a global and serious health issue. A better understanding of its potential adverse impact in infancy and childhood may lead to better intervention and treatment strategies and improved long-term outcome.
14.	Broström, Magnus, 1969- (författare) Äldre människors föreställningar om den egna framtiden, döendet och döden 2014 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Syftet med avhandlingen är att utforska äldre människors föreställningar om och förhållningssätt till den egna framtiden, döendet och döden. Det är ämnen som hittills har fått begränsad uppmärksamhet. En bakomliggande orsak till detta är att äldreforskning och dödsforskning sällan har förenats. Dessutom synliggörs äldres döende och död nästan inte alls i offentlig debatt, trots att ålderdomen är den fas i livet då döden normalt inträffar. Studien bygger på kvalitativa intervjuer med 27 äldre kvinnor och män i åldrarna 70–91 år, vilka alla bodde i ordinärt boende och betraktade sig själva som relativt friska. Genomförande, analys och tolkning av intervjuerna har utgått från ett livsloppsperspektiv, där både en abduktiv och en hermeneutisk ansats tillämpades. I analys och tolkning framkom kontrasterande mönster i de intervjuades funderingar på den egna framtiden och döden, i deras samtal med någon om döden, i deras erfarenheter av döende och död, och i vad de trodde hände efter döden. Resultaten visar också att funderingar och agerande inför en krympande framtid utgjorde centrala inslag i de äldres vardag och att de intervjuade laborerade med olika tidshorisonter. Ett annat resultat handlar vad som är rätt tidpunkt i livet för att fundera på döden, samtala med andra om döden, för att planera inför döden och för ett ”efter döden”. Det är en komplex bild av äldres föreställningar om den egna framtiden, döendet och döden som framkommit, där teman som åldersmönster, ett förlängt livslopp, ansvar, kontroll och värdighet är centrala inslag. Avhandlingens resultat kan bidra till en bättre förståelse för äldre människors situation i ljuset av en krympande framtid, döende och död.
15.	Elfström, Maria, et al. (författare) Decisive Situations Affecting Partners Support to Continuous Positive Airway Pressure-Treated Patients With Obstructive Sleep Apnea Syndrome A Critical Incident Technique Analysis of the Initial Treatment Phase 2012 Ingår i: Journal of Cardiovascular Nursing. - : Lippincott, Williams and Wilkins. - 0889-4655 .- 1550-5049 .- 1474-5151 .- 1873-1953. ; 27:3, s. 228-239 Tidskriftsartikel (refereegranskat)abstract Background and Research Objective: Effective treatment of obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) can reduce morbidity and mortality, but adherence rates are low. The partner has an important role in supporting the patient, but this role may be adversely affected by difficulties during the early phase of the CPAP initiation. The aim of this study was to explore and describe decisive situations affecting partners support to patients with OSAS and how the partners manage these situations during the initial phase of CPAP treatment. Subjects and Methods: A qualitative descriptive design using critical incident technique was used. A total of 542 decisive situations affecting partners support and 222 situations describing managing were collected by means of interviews with 25 strategically selected partners of patients with CPAP treated OSAS. Results: Adverse effects, limited effect, practical and psychosocial problems, limited presence, and inappropriate initiation emerged as negative influences on the partners support. A well-functioning treatment, improvements, high motivation, and receiving support from others were identified as positive influences on the partners support. The partner managed the situations by letting the patient handle the CPAP treatment by himself/herself, by handling the treatment together with the patient, or taking over the handling of CPAP treatment. Conclusion: Increased knowledge about the different situations that affect the partners support negatively or positively and how these situations are managed by partners can be used in educational situations involving both patients and partners during CPAP initiation.
16.	Eriksson, Marie, et al. (författare) Gait pattern in children with arthrogryposis multiplex congenita 2010 Ingår i: Journal of Children's Orthopaedics. - : SAGE Publications. - 1863-2521 .- 1863-2548. ; 4:1, s. 21-31 Tidskriftsartikel (refereegranskat)abstract Purpose: Lower limb contractures and muscle weakness are common in children with arthrogryposis multiplex congenita (AMC). To enhance or facilitate ambulation, orthoses may be used. The aim of this study was to describe gait pattern among individuals wearing their habitual orthotic devices. Methods: Fifteen children with AMC, mean age 12. 4 (4. 3) years, with some lower limb involvement underwent 3-D gait analysis. Three groups were defined based on orthosis use; Group 1 used knee-ankle-foot orthoses with locked knee joints, Group 2 used ankle-foot orthoses or knee-ankle-foot orthoses with open knee joints and Group 3 used no orthoses. Results: The greatest trunk and pelvis movements in all planes and the greatest hip abduction were observed in Group 1, compared to Groups 2 and 3, as well as to the gait laboratory control group. Maximum hip extension was similar in Groups 1 and 2, but in Group 3, there was less hip extension and large deviations from the control data. Lower cadence and walking speed were observed in Group 1 than in Groups 2 and 3. The step length was similar in all groups and also with respect to the gait laboratory reference values. Conclusions: Children with AMC were subdivided according to orthoses use. Kinematic data as recorded with 3-D gait analysis showed differences among the groups in trunk, pelvis and knee kinematics, and in cadence and walking speed. The step length was similar in all groups and to the gait laboratory reference values, which may be attributable to good hip extension strength in all participants.
17.	Igelström, Helena, 1976- (författare) Physical Activity and Eating Behaviour Changes in Patients with Obstructive Sleep Apnea Syndrome 2013 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract This thesis aimed at developing and evaluating a tailored behavioural sleep medicine intervention for enhanced physical activity and healthy eating in patients with obstructive sleep apnea syndrome (OSAS) and overweight.Participants with moderate or severe OSAS (apnea-hypopnea index ≥15) and obesity (Studies I-II) or overweight (Studies III-IV), treated with continuous positive airway pressure (CPAP) (Studies I-II) or admitted to CPAP treatment (Studies III-IV), were recruited from the sleep clinic at Uppsala University Hospital, Sweden. Semi-structured individual interviews were analysed using qualitative content analysis (Study I). Data on moderate-to-vigorous physical activity (MVPA) and sedentary time were collected with three measurement methods and analysed regarding the level of measurement agreement (Study II). Potential disease-related and psychological correlates for the amount of MVPA, daily steps and sedentary time were explored using multiple linear regression (Study III). Physical activity and eating behaviour changes were examined after a six month behaviour change trial (Study IV). A tailored behavioural sleep medicine intervention targeting physical activity and healthy eating in combination with first- time CPAP treatment was compared with CPAP treatment and advice on the association between weight and OSAS.According to participants’ conceptions, a strong incentive is needed for a change in physical activity and bodily symptoms, external circumstances and thoughts and feelings influence physical activity engagement (Study I). Compared with accelerometry, the participants overestimated the level of MVPA and underestimated sedentary time when using self-reports (Study II). The participants spent 11 hours 45 minutes (71.6% of waking hours) while sedentary. Fear of movement contributed to the variation in steps and sedentary time. Body mass index was positively correlated to MVPA (Study III). The experimental group increased intake of fruit and fish and reduced more weight and waist circumference compared with controls. There were no changes in physical activity (Study IV).The novel tailored behavioural sleep medicine intervention combined with first-time CPAP facilitated eating behaviour change, with subsequent effects on anthropometrics, but it had no effects on physical activity and sedentary time. Fear of movement may be a salient determinant of sedentary time, which has to be further explored in this population. The results confirm sedentary being a construct necessary to separate from the lower end of a physical activity continuum and highlight the need of developing interventions targeting sedentary behaviours specifically.
18.	Johansson, Gudrun M., et al. (författare) Assessment of arm movements during gait in stroke : the Arm Posture Score 2014 Ingår i: Gait & Posture. - : Elsevier BV. - 0966-6362 .- 1879-2219. ; 40:4, s. 549-555 Tidskriftsartikel (refereegranskat)abstract The purpose of the study was to apply the Arm Posture Score (APS) to a stroke population, since comprehensive measures to quantify arm swing in the affected and non-affected arms during gait are lacking. A further aim was to investigate how gait speed and upper limb function estimated by clinical measures are related to the APS in the stroke group. The APS is the summarized root mean square deviation (RMSD) from normal, based on kinematics. Four arm movements (sagittal and frontal planes) as well as six arm movements (incorporating transversal plane) were included in the calculation of APS, referred to as APS4 and APS6, respectively. The study population consisted of 25 persons with stroke and 25 age- and gender-matched controls. The APS measures were significantly different between the affected and non-affected arms, as well as between the affected arm and the non-dominant arm of the controls (p≤0.001). Spasticity significantly influenced both APS measures, while speed only had a significant effect on the APS4. The APS measures correlated significantly to clinical measures of upper limb function. Both APS measures seem to be useful indices to quantify and discriminate between impaired and normal arm swing during gait after stroke. The variability of rotational arm movements needs to be studied further before considering the additional value of the APS6 over the APS4. When interpreting the APS, complementary kinematics should be taken into account, as the single value of the APS gives no information about the direction of the deviation.
19.	Johansson, Peter, et al. (författare) Clinical characteristics and mortality risk in relation to obstructive and central sleep apnoea in community-dwelling elderly individuals: a 7-year follow-up 2012 Ingår i: Age and Ageing. - : Oxford University Press (OUP): Policy A. - 0002-0729 .- 1468-2834. ; 41:4, s. 468-474 Tidskriftsartikel (refereegranskat)abstract Methods: a total of 331 community-dwelling elderly aged 71-87 years underwent a clinical examination and one-night polygraphic recordings in their homes. Mortality data were collected after seven years. Results: a total of 55% had SDB, 38% had OSA and 17% had CSA. Compared with those with no SDB and OSA, more participants with CSA had a left ventricular ejection fraction less than 50% (LVEF less than 50%) ischaemic heart disease (IHD) and transient ischaemic attack (TIA)/stroke. There was no difference in the rate of IHD and TIA/stroke between OSA and no SDB, but more LVEF less than 50% was found in those with OSA. CSA significantly increased the risk for all-cause (P = 0.002) and CV mortality (P = 0.018) by more than two times. After adjustments for CV disease, diabetes and the biomarker NT-pro-brain natriuretic peptide CSA associations to all-cause mortality and CV mortality lost significance. Conclusion: OSA, in persons greater than 75 years does not appear to be associated with cardiovascular disease (CVD) disease or mortality, whereas CSA might be a pathological marker of CVD and impaired systolic function associated with higher mortality.
20.	Johansson, Peter, et al. (författare) Determinants of global preceived health in community-dwelling elderly screened for heart failure and sleep-disordered breathing. 2010 Ingår i: European Journal of Cardiovascular Nursing. - : Wolters Kluwer. - 1474-5151 .- 1873-1953 .- 0889-4655 .- 1550-5049. ; 25:5, s. 16-26 Tidskriftsartikel (refereegranskat)abstract The relationships between heart failure (HF), sleep-disordered breathing (SDB), insomnia, depressive symptoms, and excessive daytime sleepiness (EDS), as well as their relationship to Global Perceived Health (GPH) in an elderly community-dwelling population, have not been explored. Data from 331 community-dwelling elderly (71-87 years old) were collected by echocardiography, polygraphy, and specific questionnaires. Factor analyses and structural equation modeling were used to explore the relationships between HF, SDB, sleep, psychosocial factors, and GPH. Exploratory and confirmatory factor analyses derived a 5-factor model representing SDB, insomnia, systolic function, breathlessness/physical function, and psychosocial function. Structural equation modeling analyses were used to explore the relationships between the 5 factors and to GPH. Sleep-disordered breathing had a weak effect on systolic function, but no effects on any of the other factors or GPH were found. Psychosocial function and breathlessness/physical function directly affected GPH. Indirect effects on GPH, mediated by psychosocial function, were found for breathlessness/physical function and insomnia. Systolic function also had an indirect effect on GPH. The fact that SDB in the elderly has no obvious negative associations to sleep complaints or GPH does not exclude them from being adequately treated for SDB. However, the present study has shown that SDB, by means of self-rated sleep complaints and health-related quality of life, can be problematic to detect. Psychosocial function was the most important factor for perceived GPH as it had a direct effect, as well as mediated the factors breathlessness/physical function and insomnia effects, on GPH. This study indicates that interventions in clinical practice targeting psychosocial dysfunction, such as depressive symptoms, could help to improve GPH in the elderly with or without HF.
21.	Johansson, Peter, et al. (författare) Difficulties in identification of sleep disordered breathing in an outpatient clinic for heart failure– A case study 2014 Ingår i: Annals of Nursing and Practice. - : JSciMedCentral. ; 1:3 Tidskriftsartikel (refereegranskat)abstract Sleep disordered breathing (SDB) is prevalent in patients with heart failure (HF). The clinical signs of newly diagnosed HF and untreated SDB may overlap and patients in need of SDB treatment can therefore be difficult to identify in patients participating in disease management programmes (DMP). The aim was to describe the care process of two patients with HF involved in a DMP, focusing on the difficulties to identify and initiate treatment of SDB.A prospective case study design was used to follow one male (70 yrs) and one female (74 yrs) patient during 18 months at a Swedish University hospital. It took 5 to 10 months from diagnosis of HF until optimal treatment was reached for their heart conditions and 12 to 17 months until SDB was treated. None of the patients complained of poor sleep, but suffered from fatigue. In the male SDB was detected by the wife’s complaints of her husband’s snoring, apnoeas and restless sleep. In the female, SDB was detected after a detailed assessment of fatigue which was shown to be sleepiness. After optimal treatment of HF but before imitation of SDB treatment both cases cardiac function improved. For the female case improvements also were found in the blood pressure. SDB treatment improved fatigue in both patients. Initiation of HF treatment and self-care routines, as well as identification of SDB is complex and time consuming. Treatment of HF and SDB can improve sleep, cardiac function as well as disturbing associated symptoms.
22.	Johansson, Peter, et al. (författare) Sleep disordered breathing in community dwelling elderly-associations to cardiovascular disease, impaired systolic function and mortality. A six year follow-up in EUROPEAN HEART JOURNAL, vol 31, issue , pp 234-234 2010 Ingår i: EUROPEAN HEART JOURNAL. - : Oxford University Press. ; , s. 234-234 Konferensbidrag (refereegranskat)abstract n/a
23.	Johansson, Peter, et al. (författare) Sleep disordered breathing in community dwelling elderly: Associations with cardiovascular disease, impaired systolic function, and mortality after a six-year follow-up 2011 Ingår i: Sleep Medicine. - : Elsevier. - 1389-9457 .- 1878-5506. ; 12:8, s. 748-753 Tidskriftsartikel (refereegranskat)abstract Introduction: Sleep disordered breathing (SDB), cardiovascular disease (CVD) and impaired cardiac function are common in elderly people. We investigated the association of SDB and mortality in a community dwelling elderly population, considering CVD and objectively measured impaired cardiac function have been poorly studied thus far. less thanbrgreater than less thanbrgreater thanAim: To investigate whether SDB is a factor that affects mortality in elderly people, with a focus on those with CVD and/or signs of impaired cardiac function. less thanbrgreater than less thanbrgreater thanMethods: A prospective cohort design was used and 331 community dwelling elderly aged 71-87 years underwent one-night polygraphic recordings in the subjects homes. CVD and systolic function were objectively established. Mortality data were collected after 6 years. less thanbrgreater than less thanbrgreater thanResults: in the total population there were no significant associations between mortality and SOB. In those with CVD and impaired systolic function, as measured by NT-proBNP, oxygen desaturation index (ODI) andgt;= 10 was associated with mortality. The hazard ratio of 3.0 (Cl 95% 1.1-8.6, p = 0.03) remained statistically significant after adjustments for age, gender, diabetes and plasma values of NT-proBNP. less thanbrgreater than less thanbrgreater thanConclusion: SOB in community dwelling elderly has no overall association to mortality irrespective of degree of SDB. However, hypoxic events (i.e., ODI andgt;= 10) were associated with mortality in the group who had CVD in combination with impaired systolic function.
24.	Johansson, Peter, et al. (författare) Sleep disordered breathing, insomnia, and health related quality of life - A comparison between age and gender matched elderly with heart failure or without cardiovascular disease 2010 Ingår i: European Journal of Cardiovascular Nursing. - : Elsevier Science B.V., Amsterdam.. - 1474-5151 .- 1873-1953. ; 9:2, s. 108-117 Tidskriftsartikel (refereegranskat)abstract Aims: The aims of this study are (I) to compare the prevalence of sleep disordered breathing (SDB) and insomnia between elderly with heart failure (HF) and age and gender matched elderly without cardiovascular disease (CVD), and (II) to examine the association between HF, SDB and insomnia, as well as their impact on health related quality of life (Hr-QoL). Methods: Three hundred and thirty-one elderly (71-87 years) community-living individuals underwent sleep recordings and echocardiography. Questionnaires assessed insomnia and Hr-QoL. Comparisons were made between age and gender matched individuals with HF (n=36) and without CVD (n=36). Results: The HF group had higher mean apnoea-hypopnoea index (17.6 vs. 6.3, pless than0.001). Moderate/severe SDB was found in 42% of those with HF vs. 8% in those without CVD (p=0.001). Those with HF had more difficulties maintaining sleep (DMS) (72% vs. 50%, p=0.05) and excessive daytime sleepiness (EDS) (25% vs. 8%, p=0.05) and scored worse Hr-QoL in five of eight SF-36 domains. In regression analysis SDB had no association to Hr-QoL. DMS associated to the physical-, and non restorative sleep to the mental domain of Hr-QoL. SDB had no correlations to insomnia or EDS. Conclusions: SDB, DMS and EDS are more common in elderly with HF. SDB is not an obvious cause for sleep complaints or poor Hr-QoL in elderly.
25.	Klets, Olesya, et al. (författare) Comparison between a subject-specific and a scaled generic musculoskeletal model of the lower extremities in a subject with unilateral cerebral palsy 2011 Ingår i: Clinical Biomechanics. - 0268-0033 .- 1879-1271. Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract The purpose of this paper was to develop methods to build a subject-specific musculoskeletal model of the lower extremities based on MRIs of a subject with unilateral CP, and to determine whether a scaled generic musculoskeletal model is accurate enough to characterize MTLs and MALs of 70 muscles in both lower limbs during gait in a subject with unilateral cerebral palsy. We found, that the generic models produced accurate values for changes in MTL during gait for almost all muscles, except adductor longus, adductor magnus, adductor brevis, quadratus femoris, pectineus, extensor digitorum longus, soleus, lateral gastrocnemius, and medial gastrocnemius. MALs computed from the scaled generic model, however, differed considerably from those computed from the subject-specific model. Upon comparison of hip, knee and ankle MALs in affected and non-affected sides of the lower extremities, the scaled generic model generally failed to identify level arm dysfunction in the subject with unilateral CP
26.	Klets, Olesya, et al. (författare) Moment-generating biomechanical factors of hip muscles in persons with unilateral with subject-specific models 2012 Ingår i: Journal of Applied Biomechanics. - 1065-8483 .- 1543-2688. Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)
27.	Lidbeck, Cecilia M., et al. (författare) Postural Orientation During Standing in Children With Bilateral Cerebral Palsy 2014 Ingår i: Pediatric Physical Therapy. - 0898-5669 .- 1538-005X. ; 26:2, s. 223-229 Tidskriftsartikel (refereegranskat)abstract Purpose: To investigate postural orientation and maintenance of joint position during standing in children with bilateral spastic cerebral palsy (BSCP). Methods: Standing was examined with 3-D motion analysis in 26 children with BSCP, and 19 children typically developing (TD). Two groups of children with cerebral palsy (CP) were analyzed: 15 who were able to maintain standing without support and 11 who needed support. Results: Children with CP stood with more flexion than children TD. In the CP groups, children standing without support stood more asymmetrically with less hip and knee flexion and less movement than those who required support. Conclusion: Children with CP had varying abilities to stand and maintain standing posture with or without support. Both CP groups stood with more flexion than their potential passive joint angle, more obvious in children requiring support. Investigations on how muscle strength and spatial perception influence posture remains to be explored.
28.	Mörelius, Evalotte, 1965-, et al. (författare) The Stockholm Neonatal Family-Centered Care Study : Effects on Salivary Cortisol in Infants and their Mothers 2011 Konferensbidrag (refereegranskat)abstract BACKGROUND: Parental involvement in the care of preterm infants in neonatal intensive care units (NICUs) is common, but little is known about the effect on stress responses in mothers and infants.AIMS:To evaluate the effect of family-centered care on salivary cortisol reactivity in mothers and preterm infants and the correlation between the mothers’ and the preterm infants’ salivary cortisol levels.METHODS:This study is part of a randomized controlled trial conducted at two level-II NICUs, including Family Care (FC), where parents were able to stay 24 hours/day from admission to discharge, and Standard Care (SC). To investigate the cortisol response, saliva was collected from 289 preterm infants and their mothers before and after a diaper change at the time of discharge.RESULTS:No significant differences were found between the two groups in salivary cortisol reactivity, either in mothers or in infants. The results revealed a correlation between preterm infants’ and their mothers’ baseline and response cortisol in the FC group: r=0.31 (p=0.001) and r=0.24 (p=0.01), respectively. Such correlation was not observed in the SC group: r=0.14 (p=0.14) and r=0.18 (p=0.07), respectively.CONCLUSIONS: Family-centered care had no effect on salivary cortisol reactivity during diaper change. However, sharing the same environment may increase the concordance between preterm infants’ and their mothers’ salivary cortisol levels.
29.	Mörelius, Evalotte, et al. (författare) The Stockholm Neonatal Family-Centered Care Study : Effects on salivary cortisol in infants and their mothers 2012 Ingår i: Early Human Development. - : Elsevier. - 0378-3782 .- 1872-6232. ; 88:7, s. 575-581 Tidskriftsartikel (refereegranskat)abstract Background: Parental involvement in the care of preterm infants in neonatal intensive care units (NICUs) is common, but little is known about the effect on stress responses in mothers and infants. Aims: The aim of this study is to evaluate the effect of family-centered care on salivary cortisol reactivity in mothers and preterm infants and the correlation between the mothers and the preterm infants salivary cortisol levels. Methods: This study is part of a randomized controlled trial conducted at two level-II NICUs, including Family Care (FC), where parents were able to stay 24 h/day from admission to discharge, and Standard Care (SC). To investigate the cortisol response, saliva was collected from 289 preterm infants and their mothers before and after a diaper change at the time of discharge. Results: No significant differences were found between the two groups in salivary cortisol reactivity, either in mothers or in infants. The results revealed a correlation between preterm infants and their mothers baseline and response cortisol in the FC group: r = 0.31 (p = 0.001) and r = 0.24 (p = 0.01), respectively. Such correlation was not observed in the SC group: r = 0.14 (p = 0.14) and r = 0.18 (p = 0.07), respectively. Conclusions: Family-centered care had no effect on salivary cortisol reactivity during diaper change. However, sharing the same environment may increase the concordance between preterm infants and their mothers salivary cortisol levels.
30.	Riad, Jacques, et al. (författare) Are Muscle Volume Differences Related to Concentric Muscle Work During Walking in Spastic Hemiplegic Cerebral Palsy? 2012 Ingår i: Clinical Orthopaedics and Related Research. - : Ovid Technologies (Wolters Kluwer Health). - 0009-921X .- 1528-1132. ; 470:5, s. 1278-1285 Tidskriftsartikel (refereegranskat)abstract Background: Individuals with spastic hemiplegic cerebral palsy are typically high functioning and walk without assistive devices. The involved limb is usually smaller and shorter, although it is not clear whether the difference in muscle volume has an impact on walking capacity. Questions/purposes: We determined the volume of muscles important for propulsion and related that volume to concentric muscle work during walking on the hemiplegic and noninvolved sides in patients with cerebral palsy. Patients and Methods: We studied 46 patients (mean age, 17.6 years; range, 13-24 years) with spastic hemiplegic cerebral palsy. We assessed muscle volume using MRI and concentric muscle work in the sagittal plane from the hip, knee, and ankle using three-dimensional gait analysis. Patients were classified by Winters' criteria to assess the involvement of cerebral palsy and movement pattern during walking. Results: On the hemiplegic side, muscles were smaller, except for the gracilis muscle, and concentric muscle work from the ankle plantar flexors, knee extensors, and hip flexors and extensors was lower compared to the noninvolved side. Hip extensor work was higher on the hemiplegic and the noninvolved sides compared to a control group of 14 subjects without cerebral palsy. Hemiplegic to noninvolved volume ratios correlated with work ratios (r = 0.40-0.66). The Winters classification and previous calf muscle surgery predicted work ratios. Conclusions: Our observations of smaller muscles on the hemiplegic side and changes in muscle work on both sides can help us distinguish between primary deviations that may potentially be treatable and compensatory mechanisms that should not be treated.
31.	Riad, Jacques, et al. (författare) Arm posture score and arm movement during walking : A comprehensive assessment in spastic hemiplegic cerebral palsy 2011 Ingår i: Gait & Posture. - : Elsevier B.V.. - 0966-6362 .- 1879-2219. ; 33:1, s. 48-53 Tidskriftsartikel (refereegranskat)abstract Patients with hemiplegic cerebral palsy often have noticeably deviant arm posture and decreased arm movement. Here we develop a comprehensive assessment method for the upper extremity during walking.Arm posture score (APS), deviation of shoulder flexion/extension, shoulder abduction/adduction, elbow flexion/extension and wrist flexion/extension were calculated from three-dimensional gait analysis. The APS is the root mean square deviation from normal, similar to Baker's Gait Profile Score (GPS)[1].The total range of motion (ROM) was defined as the difference between the maximum and minimum position in the gait cycle for each variable. The arm symmetry, arm posture index (API) was calculated by dividing the APS on the hemiplegic side by that on the non-involved side, and the range of motion index (ROMI) by dividing the ROM on the hemiplegic side by that on the non-involved side.Using the APS, two groups were defined. Group 1 had minor deviations, with an APS under 9.0 and a mean of 6.0 (95% CI 5.0–7.0). Group 2 had more pronounced deviations, with an APS over 9.0 and a mean of 13.1 (CI 10.8–15.5) (p=0.000). Total ROM was 60.6 in group 1 and 46.2 in group 2 (p=0.031). API was 0.89 in group 1 and 1.70 in group 2 (p<0.001). ROMI was 1.15 in group 1 and 0.69 in group 2 (p=0.003).APS describes the amount of deviation, ROM provides additional information on movement pattern and the indices the symmetry. These comprehensive objective and dynamic measurements of upper extremity abnormality can be useful in following natural progression, evaluating treatment and making prognoses in several categories of patients.
32.	Stålkrantz, Anna, et al. (författare) Everyday life for the spouses of patients with untreated OSA syndrome 2012 Ingår i: Scandinavian Journal of Caring Sciences. - : Wiley. - 0283-9318 .- 1471-6712. ; 26:2, s. 324-332 Tidskriftsartikel (refereegranskat)abstract The aim of this study was to generate a theoretical model describing concerns for spouses of patients with untreated obstructive sleep apnoea syndrome (OSAS) and how they manage these concerns in their everyday life. Twelve spouses were interviewed about their experiences and how they manage everyday life. The interviews were analysed according to the Grounded Theory method as described by Strauss and Corbin. Two main categories emerged from the data: ‘Social adjustment’ and ‘New feelings’. ‘Social adjustment’ reveals how the spouses made adjustments in their daily lives, both according to their partners’ tiredness and owing to their own fatigue. ‘New feelings’ reveals emotional reactions related to the effects of their partner’s illness and the impact it had on the spouse’s everyday life. These two main categories could be seen in relation to four dimensions describing how the spouses manage their everyday life: ‘Sacrificing’, ‘Controlling’, ‘Changing’ and ‘Understanding’. The results show how the spouses made adjustments in everyday life and how their feelings were affected by their partner’s OSAS. Healthcare personnel could use information from this study to gain a deeper understanding and knowledge of what spouses of untreated patients with OSAS experience as their main concerns and how they manage their everyday life. This knowledge can be used to improve the support to the spouses, as well as in the educational situation concerning the illness, as well as the treatment.
33.	Sunnergren, Ola, 1971-, et al. (författare) How should sensory function in the oropharynx be tested? Cold thermal testing; a comparison of the methods of levels and limits 2010 Ingår i: Clinical Neurophysiology. - : Elsevier Science B.V., Amsterdam.. - 1388-2457 .- 1872-8952. ; 121:11, s. 1886-1889 Tidskriftsartikel (refereegranskat)abstract Objective: Several studies indicate an upper airway peripheral neuropathy in obstructive sleep apnea syndrome (OSAS). The sensation of cold, as measured by cold detection thresholds (CDT), in the oropharynx has been shown to be compromised in patients with sleep apnea and, to a lesser extent, habitual snoring. To reveal whether this neuropathy is part of the pathogenetic process of OSAS, longitudinal studies of snorers are needed. The objective of the present study was to establish the test-retest repeatability for the two most commonly used thermal testing methods: the reaction time exclusive method of levels (MLE) and the method of limits (MLI). Methods: Forty non-snoring subjects were tested at the soft palate and the lip at two separate occasions (mean interval 45 days) using a Medoc TSA - 2001 equipment with an intra-oral thermode. Results: With MLE mean CDTs were lower for both the lip and soft palate than with MLI. However, MLI showed a better test-retest repeatability (r = 2.2 vs. 2.6) for the soft palate. Conclusions: MLI should be used in longitudinal studies. The performance of this method is also faster. Significance: We have established a quick, safe and reliable method suitable for longitudinal studies of peripheral neuropathy in sleep apnea pathogenesis.
34.	Sunnergren, Ola (författare) Obstructive sleep apnea : General characteristics in hypertensive patients, positional sensitivity, and upper airway sensory neuropathy 2012 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Introduction: Obstructive sleep apnea (OSA) is a highly prevalent disorder, especially in populations with cardiovascular disease. Unfortunately most cases with OSA remain undiagnosed. The ability to identify OSA is important for both the individual and the society, as it is a treatable risk factor for cardiovascular disease and also associated with impaired quality of life. This could be particularly important in populations with cardiovascular disease where the most beneficiary treatment effects could be expected. However, the diagnostic process in OSA may be affected by positional dependency (a majority of OSA patients have more breathing interruptions in supine sleep compared to other sleeping positions). Based on the assumption that individuals have different proportions of supine and non-supine sleep on different nights, positional dependency may be a potential confounder in both diagnosis, classification of OSA severity and evaluation of treatment efficacy. Another aspect of OSA is that the pathogenesis is not fully understood. Data indicate that OSA might be a progressive disease, and many patients report years of snoring before witnessed apneas and symptoms occur. One hypothesis on the pathogenesis of OSA is that long-standing, snoring-induced vibrations cause neurogenic lesions in upper airway tissues, progressively damaging the reflex circuits responsible for keeping the upper airway open during sleep.Aims: To describe the occurrence of undiagnosed OSA and to identify determinants of moderate/severe OSA in patients with hypertension (study I). To describe the prevalence of position dependent OSA (POSA) and its relation to OSA severity classification (study II). To compare two methods for quantitative testing of cold sensory function (as a sign of neuropathy) in the upper airway with special focus on test-retest repeatability (study III). To evaluate signs of upper airway sensory neuropathy, by cold sensory testing, in non-snorers, snorers, and snoring OSA subjects with special reference to AHI and duration of snoring history (study IV).Methods: In study I 411 consecutive patients with hypertension from four primary care health centers in Sweden were evaluated for OSA as measured by the apnea hypopnea index (AHI) through polygraphic (PG) recordings. Different predictors for moderate/severe OSA were evaluated. In study II the PG recordings of 265 subjects were specially assessed for POSA and the relation between severity classification based on POSA and traditional OSA severity classification. In study III 40 non-snoring subjects were tested for cold detection thresholds at the soft palate and the lip at two separate occasions with two different methods (MLE/MLI). Bland-Altman analysis was used to compare test-retest repeatability. In study IV cold sensory testing of the soft palate and lip was used to evaluate signs of upper airway sensory neuropathy in both non-snorers; snorers, and subjects with OSA (groups were formed based on AHI and snoring history, n=90).Results and Conclusions: Undiagnosed OSA is common in Swedish primary care patients with hypertension, and male gender, BMI>30 kg/m2, and a clinical history of snoring and witnessed apneas are predictors of moderate/severe OSA. POSA is common both in subjects that by traditional classification had OSA as well as those without OSA. The severity of OSA, if based on total AHI, could be dependent on supine time in a substantial amount of subjects. Cold sensory testing is easily performed in the oropharynx, with acceptable test–retest repeatability. MLI is considerably faster to perform and have a slightly better repeatability than MLE. Therefore MLI should be the used method for cold thermal testing at the soft palate. Both self-reported snoring years and OSA severity are correlated to the degree of cold sensory impairment in the upper airway. Our results strengthen the hypothesis that snoring vibrations may cause a neuropathy in the upper airway, which may contribute to the progression and development of OSA.
35.	Sunnergren, Ola, 1971-, et al. (författare) Positional sensitivity as a confounder in diagnosis of severity of obstructive sleep apnea 2013 Ingår i: Sleep and Breathing. - : Springer. - 1520-9512 .- 1522-1709. ; 17, s. 173-179 Tidskriftsartikel (refereegranskat)abstract PurposeThe apnea–hypopnea index (AHI) is used to grade obstructive sleep apnea (OSA) into mild, moderate, and severe forms. Obstructive events are most common in the supine position. The amount of supine sleep thus influences total AHI. Our aim was to determine the prevalence of position-dependent OSA (POSA) and its relation to OSA severity classification as recommended by the American Academy of Sleep Medicine (AASM).MethodsTwo hundred sixty-five subjects were recruited from primary care hypertension clinics. Whole-night respiratory recordings were performed to determine the AHI in the supine and non-supine positions, respectively. POSA was defined as supine AHI twice the non-supine AHI with supine AHI ≥5.ResultsFifty-three percent had POSA, 22% had non-position-dependent OSA, and 25% had normal respiration. By AASM classification, 81 subjects did not have OSA, but 42% of them had some degree of obstruction when supine, and 5 subjects would have been classified as moderate–severe if they had only slept supine. Conversely, of the 53 classified as mild OSA, 30% would have changed to a more severe classification if they had exclusively slept supine.ConclusionsPOSA was common both in subjects that by AASM classification had OSA as well as those without. The severity of OSA, as defined by AASM, could be dependent on supine time in a substantial amount of subjects.
36.	Sunnergren, Ola, 1971-, et al. (författare) Soft Palate Sensory Neuropathy in the Pathogenesis of Obstructive Sleep Apnea 2011 Ingår i: The Laryngoscope. - : Laryngoscope. - 0023-852X .- 1531-4995. ; 121:2, s. 451-456 Tidskriftsartikel (refereegranskat)abstract Objectives/Hypothesis: In general, obstructive sleep apnea (USA) seems to be a progressive disorder whose pathogenesis is not fully understood. One hypothesis is that long-standing snoring vibrations cause a local neuropathy in the upper airway, which predisposes to obstructive events during sleep. The aim of this study was to investigate sensory function in the upper airway in a cohort of subjects comprising nonsnorers, snorers, and untreated subjects with USA, and to correlate data to apnea-hypopnea index (AHI) and duration of snoring. Study Design: Cross-sectional cohort study. Methods: Subjects were recruited from primary care hypertension clinics. Whole-night respiratory recordings were performed to determine presence and degree of USA. Three groups were formed based on AHI and snoring history: 1) nonsnorers (n = 25); 2) snorers, AHI andlt; 10 (n = 32); 3) USA subjects, AHI andgt;= 10 (n = 33). Quantitative cold sensory testing of the soft palate and lip was used to assess neuropathy. Results: There were no significant differences concerning lip sensory function between groups. Nonsnorers showed significantly lower thresholds for cold (i.e., better sensitivity) in the soft palate compared to both other groups (P andlt; .01). Snorers had lower thresholds than USA subjects (P andlt; .05). There were significant correlations (P andlt; .01) between decreased sensory function and AHI (r(s) = .41) and to duration of snoring (r(s) = .47). Conclusions: The degree of sensory neuropathy in the upper airway correlates with degree of obstructive sleep disorder. Our results strengthen the hypothesis that snoring vibrations may cause a neuropathy in the upper airway, which contributes to the progression and development of USA.
37.	Svanborg, Eva, et al. (författare) COLD SENSORY TESTING IN SNORING AND OBSTRUCTIVE SLEEP APNEA SYNDROME - EVIDENCE FOR PROGRESSIVE NERVOUS LESIONS in SLEEP, vol 34, issue , pp A152-A152 2011 Ingår i: SLEEP. - : American Academy of Sleep Medicine. ; , s. A152-A152 Konferensbidrag (refereegranskat)abstract n/a
38.	Ulander, Martin, 1980- (författare) Psychometric aspects of obstructive sleep apnea syndrome 2013 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract Introduction: Obstructive sleep apnea (OSA) is a common chronic disorder consisting of episodes with impaired breathing due to obstruction of the upper airways. Treatment with Continuous Positive Airway Pressure (CPAP) is a potentially effective treatment, but adherence is low. Several potential factors affecting adherence, e.g., subjective sleepiness and personality, are only quantifiable through questionnaires. Better knowledge about psychometric properties of such questionnaires might improve future research on CPAP adherence and thus lead to better treatment options.Aim: Study I: To describe the devlopment and initial testing of the Side Effects of CPAP treatment Inventory (SECI) questionnaire. Study II: To describe the prevalence of Type D personality in OSAS patients with CPAP treatment longer than 6 months and the association with self-reported side effects and adherence. Study III: To study whether any of the items in the Epworth Sleepiness Scale (ESS) exhibit differential item functioning and, if so, to which degree. Study IV: To examine the evolution of CPAP side effects over time; and prospectively assess correlations between early CPAP side effects and treatment adherence.Patients and Methods: In study I, SECI items were based on a literature review, an expert panel and interviews with patients. It was then mailed to 329 CPAP-treated OSAS patients. Based on this, a principal component analysis was performed, and SECI results were compared between adherent and non-adherent patients. In study II, the population consisted of 247 OSAS patients with ongoing CPAP treatment. The DS14 was used to assess the prevalence of type D personality, and SECI and adherence data from medical records were used to correlate Type D personality to side effects and adherence. In study III, the population consisted of pooled data from 1,167 subjects who had completed the ESS in five other studies. Ordinal regression and Rasch analysis were used to assess the existence of differential item functioning for age and gender. The cutoff for age was 65 years in the Rasch analysis. In study IV, SECI was sent to 186 subjects with newly diagnosed OSAS three times during the first year on CPAP. SECI results were followed over time within subjects, and were correlated to treatment dropout during the first year and machine usage time after 6 months.Results: SECI provides a valid and reliable instrument to measure side effects, and non-adherent patients have higher scores (i.e., were more bothered by side effects) than adherent patients (study I). Type D personality was prevalent in approximately 30 % of CPAP treated OSAS patients, and was associated to poorer objective and subjective adherence as well as more side effects (study II). Differential item functioning was present in items 3, 4 and 8 for age in both DIF analyses, and to gender in item 8 the Rasch analysis (study III). Dry mouth and increased number of awakenings were consistently associated to poorer adherence in CPAP treated patients. Side effects both emerged and resolved over time (study IV).Conclusions: Differences in previous research regarding side effects and CPAP adherence might be explained by differences in how side effects and adherence are defined. While some side effects are related to adherence, others are not. Side effects are furthermore not stable over time, and might be related to personality. ESS scores are also related to CPAP adherence according to previous research, but might be affected by other factors than sleepiness, such as age and possibly gender.
39.	Ulander, Martin, et al. (författare) Side effects to continuous positive airway pressure treatment for obstructive sleep apnoea : changes over time and association to adherence 2014 Ingår i: Sleep and Breathing. - : Springer Science and Business Media LLC. - 1520-9512 .- 1522-1709. ; 18:4, s. 799-807 Tidskriftsartikel (refereegranskat)abstract Continuous positive airway pressure (CPAP) is an effective treatment against obstructive sleep apnoea, but adherence is often low, and side effects are common. It is unclear from previous research whether side effects are significant causes of nonadherence. No study has examined if side effects vary within subjects over time. The aims were to (1) examine the evolution of CPAP side effects over time, and (2) prospectively assess correlations between early CPAP side effects and treatment adherence. One hundred eighty-six obstructive sleep apnoea patients from three sleep centres were prospectively enrolled. They completed the Side Effects to CPAP Inventory, where the respondent rates the frequency, magnitude and perceived impact on adherence from 15 side effects. Adherence was measured by treatment dropout and machine usage time. The most common side effects were dry mouth, increased number of awakenings, blocked up nose, mask pressure and mask leaks. While some side effects were stable over time, others could both resolve and emerge within subjects. Dry mouth, mask leakage and blocked up nose emerged within 1 year in approximately 30 % of patients who had not experienced them after 2 weeks. Increased number of awakenings and dry mouth after 1-2 weeks were significantly associated to treatment dropout during the first year and machine usage time after 6 months. While some side effects are related to adherence, most are not. Not all side effects are stable over time. This, together with differences in methodology between studies, might explain the conflicting findings in earlier research.
40.	Ulander, Martin, et al. (författare) The fairness of the Epworth Sleepiness Scale : two approaches to differential item functioning 2013 Ingår i: Sleep and Breathing. - : Springer Science and Business Media LLC. - 1520-9512 .- 1522-1709. ; 17:1, s. 157-165 Tidskriftsartikel (refereegranskat)abstract Differential item functioning (DIF) is said to exist in an item if a subject's response to the item is affected by other aspects than that which the test is intended to assess. DIF might affect the validity of a test. The aim of this study was thus to examine whether any of the items in the Epworth Sleepiness Scale (ESS) exhibits DIF regarding age or gender, and if so, to which degree. Using previously collected cross-sectional ESS data from 1,168 subjects with different clinical characteristics (61% males, mean age 67.8 year (SD 12.2 year)), ordinal regression as well as Rasch-based DIF analyses were performed. Concerning age, both DIF analyses showed DIF for age in items 3 (inactive in a public place), 4 (passenger in a car), and 8 (in a car that has stopped in traffic). The Rasch model also showed DIF for gender in item 3. The DIF magnitudes as judged by McFadden pseudo-R (2) changes were, however, only minor. ESS has small but reproducible DIF for age in items 3, 4, and 8. The detected DIF might be worth to consider in large-sample studies, although it probably has no effect on an individual basis.
41.	Wang, Ruoli, et al. (författare) Analytical decomposition can help to interpret ankle joint moment-angle relationship 2012 Ingår i: Journal of Electromyography & Kinesiology. - : Elsevier BV. - 1050-6411 .- 1873-5711. ; 22:4, s. 566-574 Tidskriftsartikel (refereegranskat)abstract Moment-angle relationship (dynamic joint stiffness) - the relationship between changes in joint moment and changes in joint angle - is useful for demonstrating interaction of kinematics and kinetics during gait. However, the individual contributors of dynamic joint stiffness are not well studied and understood, which has thus far limited its clinical application. In this study, ankle dynamic joint stiffness was analyzed and decomposed into three components in thirty able-bodied children during the stance phase of the gait. To verify the accuracy of the decomposition, the sum of decomposed components was compared to stiffness computed from experimental data, and good to very good agreement was found. Component 1, the term associated with changes in ground reaction force moment, was the dominant contribution to ankle dynamic joint stiffness. Retrospective data from eight children with juvenile idiopathic arthritis and idiopathic toe-walking was examined to explore the potential utility of analytical decomposition in pathological gait. Compared to controls, component 1 was the source of highest deviation in both pathological groups. Specifically, ankle dynamic joint stiffness differences can be further identified via two sub-components of component 1 which are based on magnitudes and rates of change of the ground reaction force and of its moment arm, and differences between the two patient groups and controls were most evident and interpretable here. Findings of the current study indicate that analytical decomposition can help identify the individual contributors to joint stiffness and clarify the sources of differences in patient groups.
42.	Wang, Ruoli (författare) Biomechanical consequences of gait impairment at the ankle and foot : Injury, malalignment, and co-contraction 2012 Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract The human foot contributes significantly to the function of the whole lower extremity during standing and locomotion. Nevertheless, the foot and ankle often suffer injuries and are affected by many musculoskeletal and neurological pathologies. The overall aim of this thesis was to evaluate gait parameters and muscle function change due to foot and ankle injury, malalignment and co-contraction. Using 3D gait analysis, analytical analyses and computational simulations, biomechanical consequences of gait impairment at the ankle and foot were explored in ablebodied persons and in patient groups with disorders affecting walking. We have characterized gait patterns of subjects with ankle fractures with a modified multi-segment foot model. The inter-segmental foot kinematics were determined during gait in 18 subjects one year after surgically-treated ankle fractures. Gait data were compared to an age- and gender-matched control group and the correlations between functional ankle score and gait parameters were determined. It was observed that even with fairly good clinical results, restricted range of motion and malalignment at and around the injured area were found in the injured limb. Moment-angle relationship (dynamic joint stiffness) - the relationship between changes in joint moment and changes in joint angle - is useful for demonstrating interaction of kinematics and kinetics during gait. Ankle dynamic joint stiffness during the stance phase of gait was analyzed and decomposed into three components in thirty able-bodied children, eight children with juvenile idiopathic arthritis and eight children with idiopathic toe-walking. Compared to controls, the component associated with changes of ground reaction moment was the source of highest deviation in both pathological groups. Specifically, ankle dynamic joint stiffness differences can be further identified via two subcomponents of this component which are based on magnitudes and rates of change of the ground reaction force and of its moment arm. And differences between the two patient groups and controls were most evident and interpretable here. Computational simulations using 3D musculoskeltal models can be powerful in investigating movement mechanisms, which are not otherwise possible or ethical to measure experimentally. We have quantified the effect of subtalar malalignment on the potential dynamic function of the main ankle dorsiflexors and plantarflexors: the gastrocnemius, soleus and tibialis anterior. Induced acceleration analysis was used to compute muscle-induced joint angular and body center of mass accelerations. A three-dimensional subject-specific linkage model was configured by gait data and driven by 1 Newton of individual muscle force. The excessive subtalar inversion or eversion was modified by offsetting up to ±20˚ from the normal subtalar angle while other configurations remain unaltered. We confirmed that in normal gait, muscles generally acted as their anatomical definitions, and that muscles can create motion in many joints, even those not spanned by the muscles. Excessive subtalar eversion was found to enlarge the plantarflexors’ and tibialis anterior’s function. In order to ascertain the reliability of muscle function computed from simulations, we have also performed a parametric study on eight healthy adults to evaluate how sensitive the muscle-induced joints’ accelerations are to the parameters of rigid foot-ground contact model. We quantified accelerations induced by the gastrocnemius, soleus and tibialis anterior on the lower limb joints. Two types of models, a ‘fixed joint’ model with three fixed joints under the foot and a ‘moving joint’ model with one joint located along the moving center of pressure were evaluated. The influences of different foot-ground contact joint constraints and locations of center of pressure were also investigated. Our findings indicate that both joint locations and prescribed degrees-of-freedom of models affect the predicted potential muscle function, wherein the joint locations are most influential. The pronounced influences can be observed in the non-sagittal plane. Excessive muscle co-contraction is a cause of inefficient or abnormal movement in some neuromuscular pathologies. We have identified the necessary compensation strategies to overcome excessive antagonistic muscle cocontraction at the ankle joint and retain a normal walking pattern. Muscle-actuated simulation of normal walking and induced acceleration analysis were performed to quantify compensatory mechanisms of the primary ankle and knee muscles in the presence of normal, medium and high levels of co-contraction of two antagonistic pairs (gastrocnemiustibialis anterior and soleus-tibialis anterior). The study showed that if the co-contraction level increases, the nearby synergistic muscles can contribute most to compensation in the gastrocnemius-tibialis anterior pair. In contrast, with the soleus-tibialis anterior co-contraction, the sartorius and hamstrings can provide important compensatory roles in knee accelerations. This dissertation documented a broad range of gait mechanisms and muscle functions in the foot and ankle area employing both experiments and computational simulations. The strategies and mechanisms in which altered gait and muscles activation are used to compensate for impairment can be regarded as references for evaluation of future patients and for dynamic muscle functions during gait.
43.	Wang, Ruoli, et al. (författare) One year follow-up after operative ankle fractures : A prospective gait analysis study with a multi-segment foot model 2010 Ingår i: Gait & Posture. - Calre, Ireland : Elsevier BV. - 0966-6362 .- 1879-2219. ; 31:2, s. 234-240 Tidskriftsartikel (refereegranskat)abstract Ankle fractures are one of the most common lower limb traumas. Several studies reported short- and long-term post-operative results, mainly determined by radiographic and subjective functional evaluations. Three-dimensional gait analysis with a multi-segment foot model was used in the current study to quantify the inter-segment foot motions in 18 patients 1 year after surgically treated ankle fractures. Data were compared to that from gender- and age-matched healthy controls. The correlations between Olerud/Molander ankle score and kinematics were also evaluated. Patients with ankle fractures showed less plantarflexion and smaller range of motion in the injured talocrural joint, which were believed to be a sign of residual joint stiffness after surgery and immobilization. Moreover, the forefoot segment had smaller sagittal and transverse ranges of motion, less plantarflexion and the hallux segment had less dorsiflexion and smaller sagittal range of motion. The deviations found in the forefoot segment may contribute to the compensation mechanisms of the injured ankle joint. Findings of our study show that gait analysis with a multi-segment foot model provides a quantitative and objective way to perform the dynamic assessment of post-operative ankle fractures, and makes it possible to better understand not only how the injured joint is affected, but also the surrounding joints.

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