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- Klässbo, Maria
(author)
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Hip disability : patient education, classification and assessment
- 2003
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Doctoral thesis (other academic/artistic)abstract
- Hip disability is common and entails activity limitations, participation restrictions and increased risk of further disability and health problems, partially due to inactivity. Hip osteoarthritis (OA), the major diagnosis, is difficult to define, especially when no joint space narrowing is seen in radiography. However, radiological hip OA can be asymptomatic. The American College of Rheumatology (ACR) has developed clinical classification criteria for symptomatic hip OA, including two range-of-motion (ROM) variables: flexion and internal rotation. It has been clinically accepted that hip OA, with joint capsule involvement, occasions a "capsular pattern" of decreased ROM, but the exact ordering of the directions is controversial. Patient education in groups is an important supplement to individual treatment and is recommended by the ACR and the European League of Associations of Rheumatology for patients with OA. The overall objective of the present thesis was to develop early educational treatment in primary care for people with hip disability - a Hip School - and to assess its effects on self-rated hip problems and health-related quality of life. Further objectives were to analyse common diagnostic and classification criteria and to improve instruments for assessing self-rated hip problems. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), available in both knee and hip formats, was translated into Swedish and tested. A Hip School led by physiotherapists was developed covering, among other things, self-help hints (e.g. advice about daily physical activity to appropriate extents for at least a total of 30 minutes, hip ROM training at the end point of motion, and not sitting for longer than 20 minutes at a time). For assessment of the Hip School, persons with hip disability were recruited to a treatment group (n = 77) or to a control group (n = 68). Self-rated hip problems were assessed with the WOMAC and health-related quality of life with the Nottingham Health Profile (NHP) before and 6 months after the Hip School. The treatment group was also tested after an additional 6 months. For 168 persons with hip disability, passive range of motion (PROM) was tested in six directions with a goniometer. PROM limitations were calculated with three different norms and arranged by size in PROM patterns. The patterns and the number of hips with patterns corresponding to proposed capsular patterns were counted. Fifty-two persons with hip disability answered an extended version of the WOMAC twice with a one-week interval. Reproducibility, percentage of zero scores (best possible score) and mean scores of symptoms and perceived importance were analysed. The results showed that the Swedish version of WOMAC is a reliable, valid, and responsive instrument with measurement qualities in agreement with the original version. Assessment of the Hip School showed that the participants reduced their pain and activity limitations and improved their health-related quality of life after 6 months with maintained effects after one year. It was not possible to predict radiological evidence of hip OA from the multitude of PROM patterns. No support was found for the existence of a hip joint "capsular pattern". The failure of the clinical signs to coincide satisfactorily with radiographic hip OA was further emphasised when the ACR clinical classification criteria were used, as they achieved a sensitivity of 85% and a specificity of 25%. Gender and other factors such as age, ROM exercise and other ROM-demanding habits influence PROM. Being male contributed almost as much as having hip OA to the risk of having decreased hip ROM. The extended instrument Hip disability and osteoarthritis outcome score (HOOS), appears to be evaluative with increased ability, especially in early-stage hip disability, to detect clinically important change over time. It is concluded that the Hip School can be a useful early treatment strategy for persons with hip disability. It is not possible to diagnose hip OA with "capsular patterns" or to classify hip OA in early cases from reduction in PROM directions. HOOS can be used to assess treatment strategies.
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- Klässbo, Maria, et al.
(author)
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I exercise to postpone death : Interviews with persons with hip and/or knee osteoarthritis who are attending an osteoarthritis school
- 2022
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In: Physiotherapy Theory and Practice. - : Taylor & Francis. - 0959-3985 .- 1532-5040. ; 38:11, s. 1667-1682
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Journal article (peer-reviewed)abstract
- Background: Physical activity (PA) and exercise constitute the first line of treatment for osteoarthritis (OA) of the hip and/or knee. Even though the symptoms may vary, OA should be considered a chronic disease and therefore PA and exercise should be performed lifelong. That needs knowledge and motivation.Purpose: The purpose of this study was to explore and create a deeper understanding of the motivational processes for PA and exercise for persons with hip and/or knee OA who have participated in a self-management program OA school that included long-term exercise supervised by physical therapists.Methods: Twenty-two in-depth interviews were conducted with 18 participants recruited from the OA school at a Physical Therapy Rehabilitation Clinic in Sweden. The interviews were analyzed with qualitative content analysis.Results: The analysis resulted in one main theme, Developing health literacy to encourage motivational processes for PA and exercise in OA and four themes: 1) meeting an established self-management program; 2) carrying my life history; 3) understanding the intelligence of the body; and 4) growing in existential motivation.Conclusion: Motivation for being physically active and to exercise, the life history in relation to PA and what creates existential motivation are important areas to ask questions about when people come to OA schools. Knowledge about the signals of the body connected to OA should be implemented in OA schools in order to motivate people to live an active life despite OA. Health literacy and the awareness of how PA can postpone death are likely to be important for existential motivation.
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- Marklund, Ingela, et al.
(author)
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Effects of lower limb intensive mass practice in poststroke patients : single-subject experimental design with long-term follow-up
- 2006
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In: Clinical Rehabilitation. - : Sage Publications. - 0269-2155 .- 1477-0873. ; 20:7, s. 568-576
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Journal article (peer-reviewed)abstract
- OBJECTIVE: To investigate the effects of two weeks of intensive mass practice with a constraint-induced movement therapy approach for the lower extremity in five chronic poststroke patients, and the persistence of effects at three and six months.DESIGN: A single-subject experimental design (SSED) was used with an AB design and follow-ups three and six months later.SETTING: Outpatient rehabilitation at Torsby Hospital in Sweden.MAIN MEASURES: Motor function in lower extremity, mobility, dynamic balance, weight-bearing symmetry and walking ability were measured on six occasions during two weeks (A phase), with the Fugl-Meyer assessment for lower extremity, the Timed Up and Go, the Step Test, the Timed Walking Test and the Six-Minute Walk Test. During the intervention's B phase, six measurements were performed with the same time intervals as in the A phase. There were follow-ups three and six months later.INTERVENTION: The intervention (B phase) consisted of bicycling, training in water, strength training, standing weight-bearing, walking up and down stairs, walking indoors and outdoors and flexibility training of the lower extremity, on all weekdays, 6 h a day for two weeks.RESULTS: The results showed improvements in 23/30 variables (77%), 12 of them statistically significant (52%). At follow-up, 22/23 improvements persisted. For example, three of five subjects walked significantly further after the intervention and the follow-ups showed that they still walked further than before the intervention.CONCLUSION: Intensive mass practice with constraint-induced movement therapy for the lower extremity can improve motor function, mobility, dynamic balance, weight-bearing symmetry and walking ability in chronic poststroke patients. Long-term follow-up showed that the effects persisted for these five subjects.
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- Marklund, Ingela, et al.
(author)
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"I got knowledge of myself and my prospects for leading an easier life" : stroke partients' experience of training with lower-limb CIMT
- 2010
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In: Advances in Physiotherapy. - : Informa Healthcare. - 1403-8196 .- 1651-1948. ; 12:3, s. 134-141
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Journal article (peer-reviewed)abstract
- Rehabilitation after stroke has changed and more studies with intensive therapy have been conducted. When a new method – here lower-limb constraint-induced movement therapy (CIMT) – is introduced, it is important to investigate participants’ own experience of the therapy. The present purpose was accordingly to describe stroke patients’ experience of training with lower-limb CIMT. Qualitative interviews with seven stroke patients who had participated in lower-limb CIMT were conducted. The interviews were transcribed verbatim and analysed with qualitative content analysis. One theme, knowledge of myself and my prospects for leading an easier life, emerged. Two main categories were found: the therapy and me and my body, with four and three categories respectively. The therapy comprised the informants’ experience of preparation for CIMT, the actual intensive training and its effects, and their views on the physiotherapists involved. Me and my body comprised the informants’ reflections on their own significance for the therapy, how the reflections had affected them and what insight into their condition CIMT had given. The informants reported that CIMT for the lower extremity gave them knowledge of their body and their prospects for leading an easier life. The intensive training instilled hope, since the functional improvements showed the possibilities of improvements, increasing the respondents’ independence and self-esteem. Even though the intensive training is tough, it was experienced as entirely necessary.
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- Marklund, Ingela, et al.
(author)
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Lower-extremity constraint-induced movement therapy improved motor function, mobility, and walking after stroke
- 2023
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In: European Journal of Physical and Rehabilitation Medicine. - : Edizioni Minerva Medica. - 1973-9087 .- 1973-9095. ; 59:2, s. 136-144
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Journal article (peer-reviewed)abstract
- BACKGROUND: To regain the ability to walk is one of the most commonly stated goals for people who have had a stroke due to its importance in everyday life. Walking ability affects patients' mobility, self-care, and social lives. Constraint-induced movement therapy (CIMT) is known to be effective in improving upper extremity outcomes post-stroke. However, there is insufficient evidence regarding its efficacy in improving lower extremity outcomes.AIM: To investigate whether a highly intensive CIMT for lower extremity (LE-CIMT) function post-stroke can improve motor function, functional mobility, and walking ability. Furthermore, it also aimed to investigate whether age, gender, stroke type, more-affected side, or time after stroke onset affect the efficacy of LE-CIMT on walking ability outcomes. DESIGN: Longitudinal cohort study.SETTING: Outpatient clinic in Stockholm, Sweden.POPULATION: A total of 147 patients mean age 51 years (68% males; 57% right-sided hemiparesis), at the sub-acute or chronic phases post-stroke who had not previously undergone LE-CIMT.METHODS: All patients received LE-CIMT for 6 hours per day over 2 weeks. The Fugl-Meyer Assessment (FMA) of the lower extremity, Timed Up and Go (TUG) test, Ten-Meter Walk Test (10MWT), and six-Minute Walk Test (6MWT) were used to assess functional outcomes before and directly after the 2-week treatment was complete as well at 3-month post-intervention.RESULTS: Compared to baseline values, FMA (P<0.001), TUG (P<0.001), 10MWT (P<0.001) and 6MWT (P<0.001) scores were statistically significantly improved directly after the LE-CIMT intervention. These improvements persisted at the 3-month post-intervention follow-up. Those who completed the intervention 1-6 months after stroke onset had statistically significant larger improvements in 10MWT compared to those who received the intervention later than 6 months after stroke onset. Age, gender, stroke type, and more-affected side did not impact 10MWT results.CONCLUSIONS: In an outpatient clinic setting, high-intensity LE-CIMT statistically significant improved motor function, functional mobility, and walking ability in middle-aged patients in the sub-acute and chronic post-stroke phases. However, studies with more robust designs need to be conducted to deepen the understanding of the efficacy of LE-CIMT.CLINICAL REHABILITATION IMPACT: High-intensity LE-CIMT may be a feasible and useful treatment option in outpatient clinics to improve post-stroke walking ability.
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- Marklund, Ingela, 1970-
(author)
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Lower-extremity constraint-induced movement therapy in individuals with stroke : improvements, experiences, and health-related quality of life
- 2023
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Doctoral thesis (other academic/artistic)abstract
- Background: Stroke is the third-leading cause of disability worldwide, and there are rehabilitation needs not only in the first year but throughout the lifetime. The ability to walk is crucial in everyday life since it affects mobility, self-care, and social activities. National guidelines recommend treating impairments with repetitive task- and goal-oriented exercises. One form of highly intensive and task-specific treatment is constraint-induced movement therapy (CIMT), a treatment method developed based on understanding brain plasticity with a behavioural explanatory model. There is insufficient evidence regarding CIMT for the lower extremities (LE-CIMT) since it has only been investigated in a few published studies involving only a small number of participants.Aim: The overall aims of this thesis were to explore the extent to which LE-CIMT (six hours per day for two weeks) can improve impaired body functions and limited activities, describe how the treatment is experienced, and investigate whether it affects the health-related quality of life (HRQoL) in individuals with stroke.Methods: This thesis contains five papers that analysed data from two study populations using quantitative and qualitative research methods. A single-subject experimental study with five subjects and a longitudinal uncontrolled cohort study with 147 subjects with stroke treated with LECIMT and follow-up after three and six months were conducted. Subjects were assessed with Fugl–Meyer assessment, the Berg balance scale (BBS), single-leg stance, step test, timed up and go with and without dual-task, ten-metre (10MWT) and six-minute (6MWT) walk tests, one repetition maximum, and weight-bearing standing on two scales. Data were analysed with the two-standard deviation band method and linear mixed modelling, controlling for heterogeneity. Seven individual semistructured interviews were performed and analysed with qualitative content analysis to explore LE-CIMT experiences. Finally, a questionnaire including RAND-36 was sent out to former LE-CIMT participants, with 106 responses (response rate 65%). Data were compared with norm-baseddata and analysed with the summary independent-samples t-test. Univariable analysis was performed to investigate the linear relationships between RAND-36 health domain scores and the 6MWT result per 100meters, time since treatment, living alone, and need for home care. Independent t-tests were used for drop-out analyses.Results: Highly intensive LE-CIMT significantly improved motor function, strength, balance, dual-task ability, mobility, and walking ability in individuals in the sub-acute and chronic post-stroke phases. They maintained or improved their weight bearing on the more affected leg to provide a more symmetric distribution. The improvements remained at the three- and six-month follow-up. There was a significant interaction for time and age. Those who completed LE-CIMT within six months after their stroke onset had significantly greater improvements in 10MWT self-selected speed during the follow-up than those who completed LE-CIMT after at least seven months. Younger participants had higher BBS scores than older participants. The informants’ experiences generated the overall theme that LE-CIMT gave them knowledge about themselves and how their body works, facilitating the opportunity to live life more easily. There was still hope and opportunity for functional improvements to increase their independence and self-esteem. While LE-CIMT was intense and challenging, it was experienced as entirely necessary. The participants had significantly reduced HRQoL, overall and by sex in physical functioning, role-functioning physical, general health (not females), and social functioning compared to the general population. A significant relationship existed between their previous 6MWT result and the HRQoL physical functioning domain. Every 100-metre improvement in the 6MWT led to a 6.45 higher physical functioning score. No other significant associations were found. The dropout analysis showed no significant differences in characteristics between the participants and those who did not complete all three assessments or answer the questionnaire.Conclusion: LE-CIMT seems helpful in improving lower extremity body functioning and activities, even a long time after the stroke, leading to persistent improvements. The patients perceived LE-CIMT as entirely necessary. LE-CIMT may be a feasible treatment option and could be conducted in both day hospital rehabilitation and outpatient settings. Six minutewalk performance predicts physical functioning in HRQoL, emphasising the importance of mobility and gait training in rehabilitation after stroke.
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