Healthcare Utilisation and Satisfaction with Care in Patients with Amyotrophic Lateral Sclerosis - An Observational Study

BACKGROUND

Patients with amyotrophic lateral sclerosis (ALS) need a large amount of healthcare services. Knowledge on use of and satisfaction with healthcare is, however, scarce.

OBJECTIVE

The objectives were to explore use and satisfaction of healthcare in patients with ALS.

METHODS

The sample consisted of patients with ALS, recruited from the ALS clinic at the Karolinska University Hospital, Stockholm, Sweden, participating in a three-year observational study. Data on healthcare utilisation were retrieved from the computerised register at Region Stockholm, Sweden. Information regarding disability, contextual factors and satisfaction with care was collected by home visits.

RESULTS

Over time, half, or less of the patients used inpatient care, whereas all used outpatient care. Half of all outpatient contacts were with providers of advanced healthcare in the home and one-fifth with allied health professionals. Nurses performing home visits composed the largest proportion of outpatient contacts. A small amount of the utilised outpatient care emerged from the ALS clinic. Patients with severe disease and longer time since diagnosis had fewer contacts with the ALS clinic. Satisfaction with care was in general stable over time with around two-thirds or more of patients being satisfied. Most patients wanted to participate in care planning, but few had.

CONCLUSION

Patients with ALS use hospital-based specialist care and other outpatient care in parallel with many healthcare providers involved. Our findings highlight the need for implementation of person-centred care to improve both coordination of care, care transitions and satisfaction with healthcare services.

Participation in social/lifestyle activities in people with multiple sclerosis: Changes across 10 years and predictors of sustained participation

Background:

Identification of people with multiple sclerosis (PwMS) with increased risk of restricted participation in social and lifestyle activities (e.g. social outings and pursuing a hobby) could guide the development of interventions supporting sustained participation.

Objective:

To explore changes in participation in complex and social everyday activities over 10 years in PwMS in relation to multiple sclerosis (MS) severity and to identify predictors of sustained participation.

Methods:

This study was based on a 10-year follow-up of 264 PwMS living in Stockholm County, Sweden. Ten-year changes in participation in social/lifestyle activities were assessed and compared between PwMS with different MS severity with the Frenchay Activities Index using age- and sex-related normative values. Multiple logistic regression analyses were used to predict sustained participation at 10 years using personal factors, disease severity and functioning as independent variables.

Results:

While a majority of people with mild MS demonstrated sustained participation (67%), a minority of PwMS moderately (26%) and severely affected by MS (5%) demonstrated sustained participation. Significant predictors of sustained participation after 10 years were walking speed ⩾1.2 m/s and ⩾32 correct responses on the Symbol Digit Modalities Test.

Conclusion:

Our findings accentuate the importance for health services to support mobility and cognition to obtain sustained participation.

Caregiver experience, health-related quality of life and life satisfaction among informal caregivers to patients with amyotrophic lateral sclerosis: A cross-sectional study

AIMS AND OBJECTIVES

This study set out to describe caregiver experience, health-related quality of life and life satisfaction among informal caregivers to patients with amyotrophic lateral sclerosis and to explore factors associated with caregivers' health-related quality of life and life satisfaction.

BACKGROUND

Knowledge about factors related to caregivers' health-related quality of life and life satisfaction is important for identification of those at risk for ill health and for development of support and care.

DESIGN

A cross-sectional study.

METHODS

Forty-nine informal caregivers and 49 patients were included. Standardised and study-specific questionnaires were used for data collection on caregiver experience (Caregiver Reaction Assessment), health-related quality of life (EuroQol Visual Analogue Scale, SF-36), life satisfaction (Life Satisfaction Checklist) and caregiver- and patient-related factors. Associations were explored by regression analyses.

RESULTS

Both positive and negative caregiver experience were reported, and health-related quality of life and life satisfaction were below national reference values. Positive experience was associated with better and negative with worse mental health-related quality of life. Factors related to informal caregivers (sex, age, living conditions) and patients (anxiety and/or depression) were related to caregivers' health-related quality and life satisfaction.

CONCLUSION

The results indicate the need to consider the individual caregiver's experience when planning services, care and support. It is important to adopt person-centred care, not only for patients but also for their informal caregivers, as factors related to both parties were associated with the informal caregivers' health-related quality of life and life satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Our study suggests that promoting positive experience and providing services and support to reduce negative aspects of caregiving might be important strategies for healthcare personnel to improve informal caregivers' health.

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

BACKGROUND

Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers' leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention's potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation.

METHODS

Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a four-month leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention.

RESULTS

Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation.

CONCLUSION

Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers' behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations.

Disability and health-related quality of life in Guillain-Barré syndrome during the first two years after onset: a prospective study

Objective: To describe changes in disability and health-related quality of life in patients with Guillain-Barré syndrome in Sweden during the first two years after onset.

Subjects: Forty-four patients were recruited from eight different hospitals, and 42 of them (mean age 52 years) were followed for two years. Evaluations were performed, primarily as home visits, at two weeks, two months, six months, one year and two years after onset.

Main measures: Disability was measured using the Katz Personal and Extended Activities of Daily Living Indexes, the Barthel Index, the Frenchay Activity Index and assessments of work capacity; health-related quality of life using the Sickness Impact Profile.

Results: At two weeks, one year and two years after onset of Guillain-Barrésyndrome, 76%, 14% and 12% of patients were dependent in personal activities of daily life (ADL); and 98%, 28% and 26% were dependent in instrumental ADL. At two weeks, all of the patients that were working before onset were unable to work owing to Guillain-Barré syndrome; at two years, 17% were unable to work. At two weeks, scores on Sickness Impact Profile were elevated in all dimensions; at two years, they remained elevated in the physical dimension and in the categories home management, work and recreation and pastimes.

Conclusions: The impact of Guillain-Barré syndrome on ADL, work, social activities and health-related quality is considerable two years after onset and presumably persists beyond this time point.

High-intensity resistance training in multiple sclerosis - An exploratory study of effects on immune markers in blood and cerebrospinal fluid, and on mood, fatigue, health-related quality of life, muscle strength, walking and cognition

BACKGROUND

High-intensity resistance training is unexplored in people with multiple sclerosis.

OBJECTIVES

To evaluate effects of high-intensity resistance training on immune markers and on measures of mood, fatigue, health-related quality of life, muscle strength, walking and cognition. Further, to describe participants' opinion and perceived changes of the training.

METHODS

Twenty patients with relapsing-remitting multiple sclerosis performed high-intensity resistance training at an intensity of 80% of one-repetition maximum, twice a week for 12 weeks. Blood and optional cerebrospinal fluid samples, and data on secondary outcome measures were collected before and after intervention. A study-specific questionnaire was used for capturing participants' opinion.

RESULTS

Seventeen participants completed the study. Plasma cytokine levels of tumor necrosis factor were significantly decreased post-intervention (p=0.001). Exploratory cytokine analyses in cerebrospinal fluid (n=8) did not reveal major changes. Significant and clinically important improvements were found in fatigue (p=0.001) and health-related quality of life (p=0.004). Measures of mood (p=0.002), muscle strength (p ≤ 0.001), walking speed (p=0.013) and cognition (p=0.04) were also improved. A majority of participants evaluated the training as very good and perceived changes to the better.

CONCLUSION

High-intensity resistance training in persons with relapsing remitting multiple sclerosis with low disability had positive effects on peripheral pro-inflammatory cytokine levels, led to clinically relevant improvements in measures of fatigue and health-related quality of life, and was well tolerated. These results provide a basis for a larger randomized trial.

A single-group pilot feasibility study of cognitive behavioural therapy in people with multiple sclerosis with depressive symptoms

PURPOSE

The aims were to evaluate (a) the feasibility of face-to-face cognitive behavioural therapy (CBT) in people with MS (PwMS) with depressive symptoms; (b) the feasibility of methods and measurements used; and (c) the outcome of the intervention before the conducting of an equivalence study of comparative methods of face-to-face CBT.

DESIGN

A single-group pilot feasibility study.

PATIENTS

PwMS (n = 15) with sub-threshold to moderate depressive symptoms, recruited at the Karolinska University Hospital, Stockholm, Sweden.

METHODS

The intervention consisted of 15-20 sessions of face-to-face CBT. Feasibility outcomes included recruitment rate, recruitment procedure and adverse events. Primary clinical outcome was the Beck Depression Inventory-II (BDI-II). Follow-ups were conducted after 3 weeks and 3 months. An estimated sample size calculation was conducted.

RESULTS

The face-to-face CBT intervention, methods and measurements used were feasible. The outcome on BDI-II indicated that face-to-face CBT is an effective method for alleviating sub-threshold to moderate depressive symptoms in PwMS.

CONCLUSION

Face-to-face CBT is feasible for use in PwMS aiming at decrease depressive symptoms. For an equivalence study, a screening process for depressive symptoms and two comparative intervention arms including traditional face-to-face CBT and low-intensity face-to-face CBT is recommended. Primary outcomes should include the BDI-II and also assessment of anxiety symptoms. Implications for Rehabilitation Depression is common among people with MS (PwMS), however, depressed PwMS do not always receive adequate treatment for depression which may lead to increased disability and worse health-related quality of life (HRQL). Cognitive behavioural therapy (CBT) is a psychological treatment method that might be beneficial for PwMS with depressive symptoms, but the evidence is still weak and further research is needed. The results from our pilot feasibility study demonstrate that for an effectiveness study of face-to-face CBT for PwMS with sub-threshold to moderate depressive symptoms the following points should be acknowledged. The design of an effectiveness study should be a randomized controlled trial including two treatment arms: traditional face-to-face CBT and a low-intensity face-to-face CBT. To increase the inclusion rate a screening process for depressive symptoms is recommended. Primary outcomes besides the Beck Depression Inventory-II should include the Hospital Anxiety and Depression Scale in order to capture anxiety symptoms and the Multiple Sclerosis Impact Scale-29 to capture HRQL.

Assessing feasibility and acceptability of study procedures: getting ready for implementation of national stroke guidelines in out-patient health care

Background

Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings.

Methods

The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records.

Results

To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting.

Conclusion

In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1177-5) contains supplementary material, which is available to authorized users.

A 10-year population-based study of people with multiple sclerosis in Stockholm, Sweden: use of and satisfaction with care and the value of different factors in predicting use of care

Background

The national strategy for treatment of chronic diseases - including MS - and changes in the Swedish welfare system, call for analyses of the use of, and patient satisfaction with, care in a long-term perspective. The aim was therefore to explore the use of care and the predictive value of personal factors, disease-specific factors and functioning on the use of care and to explore patient satisfaction with care in a 10-year perspective.

Methods

Information regarding personal factors, disease-specific factors, functioning and satisfaction with care was collected by home-visits; use of care was collected from the Stockholm County Council computerised register.

Result

Data from 121 people with MS (PwMS) was collected. Primary care accounted for the majority of all care. Neurology and Rehabilitation Departments together accounted for two-thirds of all hospital outpatient care. Rehabilitation Departments accounted for one-third of the total number of inpatient days. Lower coping capacity, impaired manual dexterity and activity of daily living dependency at baseline, together with progress in MS disability predicted a higher use of care. Overall, patient satisfaction with care was stable over time.

Conclusion

The extensive use of care offers challenges to care coordination. Implementation of person-centred care could be a strategy to increase efficacy/outcome of care.

Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health

Background

Perceived disability after stroke may persist long-term even among young individuals with mild stroke and may be related to age-related expectations of health and recovery. Thus, in order to appreciate the magnitude of perceived disability in a younger stroke population studies are needed to explore perceived health-related differences between young individuals with stroke and a matched general population. Further, to provide long-term measures by health care, relevant to the same young individuals with stroke, their perceived long-term functioning and disability associated with health need to be explored.

Methods

The generic questionnaire EQ-5D was used to compare ratings of global health and disability between young individuals living in the community up to 6 years after stroke (n = 150) and an age and geographically matched general population (n = 2661). Stroke related medical data were retrieved from medical records and the study specific questionnaire, the MYS-questionnaire, was used to assess self-rated disability associated with global health.

Results

Among the young individuals 79% had suffered a mild stroke, 45% rated a low global health compared to 15% of the matched general population and a higher proportion rated problems in mobility, self-care, usual activities and anxiety/depression. Among the young individuals with stroke, limitations and restrictions in leisure activities, work, reading as well as low level of physical activity, utilizing personal care provider or personal assistance and tiredness were negatively associated with self-rated global health (R square 0.60).

Conclusion

The negative effects of stroke, on self-rated global health among young individuals living in the community, appear to be substantial, multi factorial and long-standing which call for interdisciplinary research collaborations and team measures by health care long-term.

A population-based study of fall risk factors among people with multiple sclerosis in Stockholm county

OBJECTIVE

To identify factors associated with increased likelihood of reporting a recent fall among people with multiple sclerosis. This study was exploratory in its intent to examine sense of coherence as a contextual influence on fall risk. The study also sought to confirm that variables previously identified as fall risk factors for people with multiple sclerosis persist when tested in a population-based sample.

DESIGN

The study was cross-sectional and data was obtained in the context of a population-based study of people with multiple sclerosis living in Stockholm.

SUBJECTS

A total of 164 people with multiple sclerosis, age range 19-79 years.

METHODS

Data were gathered through established instruments. Key instruments utilized included the sense of coherence scale, the Lindmark Motor Capacity Assessment's subscale for balance, and the 10-metre walking test. A logistic regression model examined factors associated with reporting a fall in the past 3 months.

RESULTS

Of the participants, 62 (38%) reported experiencing at least one fall in the past 3 months. Reduced walking speed, impaired balance, and weak sense of coherence were associated with falls in the past 3 months.

CONCLUSION

These findings underscore the importance of examining diverse and modifiable influences on fall risk, including walking speed, balance and sense of coherence, in future studies involving people with multiple sclerosis.

A 10-year follow-up of a population-based study of people with multiple sclerosis in Stockholm, Sweden: changes in disability and the value of different factors in predicting disability and mortality

BACKGROUND

Most people with multiple sclerosis (PwMS) experience progressively worsening disability over a period of decades, thus further knowledge about the long-term changes in different areas of disability is essential.

OBJECTIVES

The aims of this study were to evaluate changes in disability over ten years in PwMS, and to explore the value of personal and disease-specific factors and depressive symptoms in predicting disability. A further aim was to explore the value of these factors as predictors of mortality.

METHODS

This study was based on a 10-year follow-up of a population-based study in Stockholm (n=166). Home visits were used to collect data on personal and disease-specific factors, walking ability, manual dexterity, cognitive function, mood, activities of daily living (ADL) and social/lifestyle activities.

RESULTS

The proportion of the study population who had disability in cognition, mood and social/lifestyle activities remained stable, while the proportion with disability in walking, manual dexterity and ADL increased. Disease severity predicted an increase in all studied variables of disability except in depressive symptoms. Older age and depressive symptoms were associated with mortality.

CONCLUSION

This study illustrates the importance of tailored interventions for PwMS and highlights the need for health-care professionals to consider the psychological aspects of the disease. Furthermore, our results indicate that the Expanded Disability Status Scale was a useful tool for predicting future disability.

Rivermead mobility index can be used to predict length of stay for elderly persons, 5 days after stroke onset

BACKGROUND

Recovery after acute stroke is expected to continue for a long time but is most rapid during the first few days after onset. Because the cost of hospital care is rising constantly, there is increasing pressure from various administrative bodies to reduce the duration of hospital stay. To select the optimal level of care for elderly patients with stroke-related disability, it is important to be aware of adequate discharge destinations and to have reliable predictors for the length of institutional stay (LOS) (ie in hospital or nursing home).

PURPOSE

The purpose of the study was to find feasible prognostic indicators for the LOS, to be used 5 days after acute stroke, in persons 65 years and older.

METHODS

One hundred fifteen consecutive persons, 65 years and older, were assessed 5 days poststroke for the following: consciousness (Glasgow Coma Scale), language (aphasia/no aphasia), perceptual (Cancellation Tasks and Block Test), emotional (lability/no lability), energy and drive (Montgomery-Åsberg Depression Scale), mental (Mini-Mental State Examination), somatosensory (normal/impaired), and urinary (continent/incontinent) functions; mobility (Rivermead mobility index [RMI]); activities of daily living (Barthel Index); and side of hemiplegia or hemiparesis. In addition, previous living arrangements (alone vs with another person), stroke characteristics, and demographic information were documented. Length of institutional stay was recorded 5 days to 3 months poststroke onset.

RESULTS

Multiple regression survival analyses showed that the factors with the greatest positive impact on short LOS, 5 days poststroke, were the following: no previous stroke; Glasgow Coma Scale ≥ 13 (mild brain injury); and RMI ≥ 4 points, corresponding to the ability to rise from a chair in less than 15 seconds and stand there for 15 seconds with or without an aid.

CONCLUSIONS

In addition to medical appraisal, the RMI ≥ 4 points, a quickly performed test, can be used to predict short LOS for persons with stroke as early as 5 days after stroke onset.

Adult norms of the perceptual threshold of touch (PTT) in the hands and feet in relation to age, gender, and right and left side using transcutaneous electrical nerve stimulation

There is a lack of standardized and quantifiable measures of touch function, for clinical work. Furthermore, it is not possible to make accurate diagnostic judgments of touch function before normative values are estimated. The objectives of this study were to establish adult norms of the perceptual threshold of touch (PTT) for the hands and feet according to age and gender and to determine the effect of right/left side, handedness, height, weight, and body mass index (BMI) on the PTT. The PTT was assessed by using a high-frequency transcutaneous electrical nerve stimulator (Hf/TENS) with self-adhesive skin electrodes in 346 adults. The PTT was identified as the level registered in mA at which the participants perceived a tingling sensation. The PTT for all participants was a median of 3.75 mA (range 2.50-7.25) in the hands and a median of 10.00 (range 5.00-30.00) in the feet. With increasing age an increase of the PTT was found. Men reported higher PTT than women. The right hand had higher PTT than the left. Handedness, height, weight, and BMI did not affect the PTT. Adult norms of the PTT in the hands for age, gender, and right/left side are presented for four age groups. The present study's estimate of the PTT in the hands could be used as adult norms. Adult norms for the feet could not be estimated because the PTT values in the feet showed a great variance.

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

Background: Multiple sclerosis has a vast impact on health, but the relationship between walking, manual dexterity, cognition and activity/participation is unclear.

Objective: The specific aims were to explore the discriminative ability of measures of walking, manual dexterity and cognition, and to identify cut-off values in these measures, for prediction of independence in personal and instrumental activities of daily living (ADL) and activity/participation in social and lifestyle activities.

Methods: Data from 164 persons with multiple sclerosis were collected during home visits with the following measures: the 2 × 5 m walk test, the Nine-hole Peg Test, the Symbol Digit Modalities Test, the Katz Personal and Instrumental ADL Indexes, and the Frenchay Activities Index (measuring frequency in social and lifestyle activities).

Results: The 2 × 5 m walk test and the Nine-hole Peg Test had high and better discriminative and predictive ability than the Symbol Digit Modalities Test. Cut-off values were identified. The accuracy of predictions was increased above all by combining the 2 × 5 m walk test and the Nine-hole Peg Test.

Conclusion: The proposed cut-off values in the 2 × 5 m walk test and the Nine-hole Peg Test may be used as indicators of functioning and to identify persons risking activity limitations and participation restrictions. However, further studies are needed to confirm the usefulness in clinical practice.

A Consensus on Stroke

Background and Purpose—

Research evidence supporting Early Supported Discharge (ESD) services has been summarized in a Cochrane Systematic Review. Trials have shown that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay. No adverse impact on the mood or well-being of patients or carers has been reported. With the implementation of many national and international stroke initiatives, we felt it timely to reach consensus about ESD among trialists who contributed to the review.

Methods—

We used a modified Delphi approach with 10 ESD trialists. An agreed list of statements about ESD was generated from the Cochrane review and three rounds of consultation completed. ESD trialists rated statements regarding team composition, model of team work, intervention, and success.

Results—

Consensus of opinion (>75% agreement) was obtained on 47 of the 56 statements. Multidisciplinary, specialist stroke ESD teams should plan and co-ordinate both discharge from hospital and provide rehabilitation in the community. Specific eligibility criteria (safety, practicality, medical stability, and disability) need to be followed to ensure this service is provided for mild to moderate stroke patients who can benefit from ESD. Length of stay in hospital, patient and carer outcome measures and cost, need to be routinely audited.

Conclusions—

We have created a consensus document that can be used by commissioners and service providers in implementing ESD services. Our aim is to promote the use of recommendations derived from research findings to facilitate successful implementation of stroke services nationally and internationally.

Perceived functioning and disability in adults with myotonic dystrophy type 1: a survey according to the International Classification Of Functioning, Disability and Health

OBJECTIVE

The purpose of this study was to describe and analyse self-rated perceived functioning, disability and environmental facilitators/barriers with regard to disease severity, using the International Classification of Functioning, Disability and Health (ICF) checklist, in adults with myotonic dystrophy type 1.

DESIGN

Cross-sectional design.

SUBJECTS

Forty-one women and 29 men with myotonic dystrophy type 1.

METHODS

A modified ICF checklist was used for self-rating of perceived problems in 29 body-function categories, difficulties in 52 activity and participation categories, and facilitators/barriers in 23 environmental-factor categories according to the verbal anchors of the ICF qualifiers. Disease severity classification was based on the muscular impairment rating scale.

RESULTS

Of the persons with myotonic dystrophy type 1, 80% perceived problems of excessive daytime sleepiness, 76% of muscle power, and 66% of energy and drive functions, while over 59% perceived difficulties in physically demanding mobility activities. Disabilities in mobility, self-care and domestic life were more frequently reported by persons with severe disease. Support from the immediate family, medicines and social security services were perceived as facilitators for 50-60% of the participants.

CONCLUSION

Disabilities and important environmental facilitators in adults with myotonic dystrophy type 1 were identified, and this clinically-relevant information can be used for developing health services for people with this condition.

The Swedish occupational fatigue inventory in people with multiple sclerosis

OBJECTIVES

To investigate the applicability of the Swedish Occupational Fatigue Inventory and its ability to identify different dimensions of fatigue in people with multiple sclerosis with varying degrees of disease severity, and the correlation of each of its 5 dimensions with the Fatigue Severity Scale.

DESIGN

An observational, prospective study.

SUBJECTS

Two hundred and nineteen outpatients: 59.5% had mild, 17% moderate and 23.5% severe disease severity; 83% received immunomodulatory treatment.

METHODS

Both questionnaires were administered at inclusion, and at 12 and 24 months. Analyses of internal consistency, item-total correlation, factor analysis and tests of correlations were performed.

RESULTS

The instrument was completed by 97% of subjects. Internal consistency was satisfactory in the dimensions Lack of energy, Lack of motivation and Sleepiness, but not in Physical exertion and Physical discomfort. Factor analysis revealed that all but 3 items (2 in Physical exertion, 1 in Physical discomfort) loaded satisfactorily in 5 dimensions. Correlations between the dimensions and the Fatigue Severity Scale were low, except for a moderate correlation found for Lack of energy.

CONCLUSION

The dimensions Lack of energy, Lack of motivation and Sleepiness appear applicable for use in people with multiple sclerosis. Further development of the physical dimensions and studies on the instrument's capacity to measure changes are needed.

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

Background

Considering the costs of multiple sclerosis (MS), it is crucial that the health-related services supplied are in accordance with needs as they are perceived by people with MS (PwMS). Satisfaction with care is related to quality of care and can provide health care providers with the means for improvement. The aim was to explore the perceived needs and satisfaction with care amongst PwMS over a two-year period, also taking sex and disease severity into consideration.

Methods

The sample consisted of 219 outpatients at a MS specialist clinic. Data on perceived needs and satisfaction with care were collected every six months using a questionnaire which included various dimensions of care. The data was analysed for the whole sample and on an individual level, as well as in subgroups with regard to sex and disease severity.

Results

There were no statistically significant variations in the proportion of PwMS with perceived needs concerning different health-related services during the study period. However, individual variations were found with regard to both perceived needs and satisfaction with care. Few PwMS perceived a continuous need for a specific service. However, the majority perceived a need for rehabilitation, assistive devices, transportation service for the disabled, psychosocial support/counselling and information on social insurance/vocational rehabilitation at least sometimes. Severe MS was associated with a greater perceived need for almost all the services studied and women experienced a need for psychosocial support/counselling to a greater extent than men. In relation to the different categories of health care staff, PwMS were most satisfied with nurses with regard to all dimensions of care. They were least satisfied with the availability of psychosocial support/counselling; and information about social insurance/vocational rehabilitation.

Conclusion

Despite the large proportion of individuals with mild disease severity in our sample, a considerable number of needs were identified of which many, on an individual level, varied over time. Key services demanded by PwMS were identified. Also the level of satisfaction with care varied and areas with a potential for improvement were identified such as the availability of rehabilitation services including an increase in the supply of psychosocial support and counselling.

Determinants of mobility and self-care in older people with stroke: importance of somatosensory and perceptual functions

BACKGROUND AND PURPOSE

Somatosensory as well as mental impairments are easily overlooked after acute stroke. Furthermore, their associations with activity limitations are not fully understood. The purpose of this study was to examine this association and whether the assessment of somatosensory functions will provide information on perceptual functions after acute stroke.

SUBJECTS AND METHODS

In 115 subjects who were > or =65 years of age, the following parameters were assessed 5 days after stroke: somatosensory (touch and proprioceptive), perceptual, and cognitive functions; depressive symptoms; mobility; and self-care.

RESULTS

Multivariate analyses showed that normal proprioceptive function was significantly associated with better mobility. Normal perceptual and touch functions were significantly associated with better self-care. Subjects with normal proprioceptive function were 8.6 times as likely to have normal perceptual function as subjects with proprioceptive impairment.

DISCUSSION AND CONCLUSION

Somatosensory and perceptual functions were significantly associated with subjects' activity levels. Normal proprioceptive function also might indicate normal perceptual function.

Combination therapy with interferon-beta and glatiramer acetate in multiple sclerosis

OBJECTIVES

To compare the effects of mono-therapy with interferon-beta (IFN-beta) or glatiramer acetate (GA) with IFN-beta + GA combination therapy for persons with multiple sclerosis (MS).

MATERIALS & METHODS

In the context of a longitudinal observational study at the MS Centre, Karolinska University Hospital, Huddinge, 83 persons with MS receiving mono-therapy at baseline were studied. Because of MS worsening 21 switched to IFN-beta + GA combination therapy for 16-24 months, and 62 remained on the same mono-therapy for 24 months. Multiple Sclerosis Functional Composite, cognitive function, depressed mood, relapse occurrence and perceived physical and psychological impact were assessed. Linear mixed-effects models and generalized estimating equations were employed to evaluate changes in each outcome over time.

RESULTS

Patients on IFN-beta + GA therapy showed greater change in odds for high perceived psychological impact. No other significant differences between treatments were found.

CONCLUSIONS

The results underline the need for a randomized trial of IFN-beta + GA in MS.

High concurrent presence of disability in multiple sclerosis

OBJECTIVES

(1) To explore functioning and concurrent presence of disabilities - concerning cognition, manual dexterity, walking, energy, mood, activities of daily living (ADL), and social/lifestyle activities - in persons with multiple sclerosis (PwMS) cared for at an outpatient MS clinic. 2) To describe the PwMS' perceived physical and psychological impact and associations with the same disabilities.

MATERIAL/METHODS

A descriptive cross-sectional study was carried out in 219 PwMS at the MS Centre, Karolinska University Hospital. Logistic regression employing proportional odds models was used to identify the associations of the disabilities with the perceived physical and psychological impact.

RESULTS

In this sample the distribution with regard to disease severity as per Expanded Disability Status Scale was; mild 59.5%, moderate 17% and severe 23.5%. Despite the high proportion with mild disease severity disability regarding cognition was found in 49%, manual dexterity 76%, walking 43%, energy 67%, mood 29%, ADL 44% and social/lifestyle activities in 48%. Two or more disabilities were found in 80%, 24 % had six or seven disabilities. Disability regarding energy, mood, walking, manual dexterity and ADL was significantly associated with increase in the perceived physical impact, whereas disability in energy and mood was significantly associated with increase in the perceived psychological impact.

CONCLUSIONS

The presence of several concurrent disabilities, some significantly associated with high perceived physical and psychological impact, in the majority of PwMS in outpatient clinics highlights the importance to identify disabilities, in particular fatigue and depressed mood, in order to supply health care interventions aiming to improve the life situation of PwMS.

Early supported discharge after stroke

Patients after stroke conventionally receive much of their rehabilitation in hospital. Services have been developed that offer patients an early discharge from hospital with more rehabilitation at home (early supported discharge). This paper sets out a systematic review of all randomized trials of early supported discharge services that included 12 trials (1659 patients). There was a reduced odds of death or dependency equivalent to 5 fewer adverse outcomes (95% confidence interval 1-10) for every 100 patients receiving an early supported discharge service (p = 0.04). Patients receiving early supported discharge services showed an 8 day reduction (p < 0.0001) in the length of hospital stay. The greatest benefits were seen in the trials evaluating a co-ordinated multidisciplinary early supported discharge team and with patients with mild-moderate disability. The experience of a trial from Stockholm is described in order to explore the potential mechanism of action of early supported discharge services. In conclusion, an illustrative case report is set out, indicating a typical patient pathway in an early supported discharge service.

A population-based study of depressive symptoms in multiple sclerosis in Stockholm county: association with functioning and sense of coherence

OBJECTIVES

To explore and analyse the prevalence of depressive symptoms in people with multiple sclerosis (PwMS), taking into account disease-related and sociodemographic factors, and also to analyse the association between depressive symptoms and functioning (tested and self-reported) and sense of coherence (SOC), respectively.

METHODS

Home visits were made to a population-based sample of 166 PwMS. Data were obtained from structured, face-to-face interviews using the Beck Depression Inventory (BDI), the Sickness Impact Profile (SIP) and the SOC scale. A range of tests were also carried out for analyses of different aspects of functioning such as cognitive function, walking capacity and manual dexterity, and structured interviews examined activities of daily living and frequency of social/lifestyle activities.

RESULTS

19% (28/149) of the people were depressed (BDI > or = 13). Depressive symptoms were associated with worse self-reported functioning on the SIP and with poor memory function, but not with any of the other tests of functioning. Depressive symptoms were associated with weak SOC, but not with any of the disease-related or sociodemographic factors studied.

CONCLUSION

The prevalence of depressive symptoms in a population-based sample of PwMS is high. Given the serious nature of depression and its association with worse self-reported functioning and weak SOC, attention to, and treatment of, mental-health problems and depression are strongly indicated in the clinical management of multiple sclerosis.

Use of healthcare, patient satisfaction and burden of care in Guillain-Barre syndrome

OBJECTIVE

The aim of this study was to investigate, in an unselected sample of patients with Guillain-Barré syndrome in Sweden, the utilization of healthcare resources, satisfaction with these resources, informal help and the burden of care on family caregivers during the first 2 years after onset.

SUBJECTS

Forty-four patients were enrolled from 8 hospitals, and 42 of them were followed for 2 years.

METHODS

Data on the utilization of hospital inpatient and outpatient care, primary care and community-based services were collected via computerized registry information, medical records and a specific protocol. Patient satisfaction and the burden on family caregivers were studied using questionnaires.

RESULTS

Forty-one patients required inpatient hospitalization for a mean of 82 days. Patients with persistent dependency during activities of daily living had significantly longer hospital stays and more days of outpatient rehabilitation. The majority of patients were satisfied with their care, but dissatisfaction was found regarding information and finances. At 2 years after onset, 26% of patients still depended on informal help. The spouses expressed increased concern and responsibility for household and family.

CONCLUSION

Patients with persistent disability due to Guillain-Barré syndrome were found to have long-term need for services from the healthcare system and informal help.

Early Supported Discharge and Continued Rehabilitation at Home After Stroke: 5-Year Follow-up of Resource Use

BACKGROUND

Early supported discharge (ESD) with continued rehabilitation at home has shown a beneficial effect on extended activities of daily living 5 years after stroke. The long-term effect of ESD on resource use has not been explored.

METHODS

At 5 years, 54 patients with mild to moderate disability, enrolled in a randomized controlled trial of ESD, were followed up. Data were collected from a county register and by interviewing the patient or the patient's spouse.

RESULTS

There were differences in mean length of hospitalization, 51 versus 32 days (P = .02). There was no significant difference between the groups in regard to total outpatient rehabilitation, ESD visits included, but there was a difference in where the services were obtained. The ESD group had more rehabilitation at home (ESD service) and the control group had more outpatient rehabilitation (P = .04), including physiotherapy in primary care (P = .05). There were no other differences.

CONCLUSION

We conclude that, 5 years after stroke, our ESD service was favorable with regard to resource use.

Hemiplegic Limb Synergies in Stroke Patients

OBJECTIVE

To describe the extent to which the voluntary movements of hemiparetic stroke patients are restricted to the hemiplegic limb synergies (which are marked by the inability to master individual joint movements) described by Brunnström. The study also aimed to describe the extent to which the synergies are related to functioning.

DESIGN

In a prospective observational study design, 64 consecutive hemiparetic stroke patients were assessed with Brunnström's hemiplegic limb synergies, the modified Ashworth scale for spasticity, the Rivermead mobility index, and the Barthel ADL index.

RESULTS

Three months after stroke, 8 of the 64 patients were moving completely or partly within the synergies. All patients whose movements were restricted to the synergies also exhibited spasticity. Hemiparetic patients whose movements were restricted to the synergies had significantly worse functioning scores than hemiparetic patients whose movements were not restricted to the synergies although severe disabilities were seen in both groups.

CONCLUSIONS

Three months after stroke, the voluntary movements of only 13% of hemiparetic stroke patients were restricted to the synergies. The synergies were associated with spasticity and activity limitations. The use of the synergies might only be suitable for a small fraction of hemiparetic patients-namely, those displaying spasticity.

Spasticity and its association with functioning and health-related quality of life 18 months after stroke

BACKGROUND

There is no consensus concerning the presence of spasticity or the relationship between spasticity and functioning and spasticity and health-related quality of life (HRQL) in the stable phase after stroke.

OBJECTIVE

The aim of the present study was to describe, 18 months after stroke, the frequency of spasticity and its association with functioning and HRQL.

METHODS

In a cohort of 66 consecutive patients with first-ever stroke, studied prospectively, the following parameters were assessed 18 months after stroke: spasticity, by the Modified Ashworth Scale (0-4 points with 1+ as the modification), muscle stiffness, by self-report, abnormal tendon reflexes, by physical examination, motor performance, by the Lindmark Motor Assessment Scale, mobility, by the Rivermead Mobility Index, activities of daily living, by the Barthel Index, and HRQL, by the Swedish Short Form 36 Health Survey Questionnaire (SF-36).

RESULTS

Of 66 patients studied, 38 were hemiparetic; of these, 13 displayed spasticity, 12 had increased tendon reflexes, and 7 reported muscle stiffness 18 months after stroke. Weak (r < 0.5) to moderate (r = 0.5-0.75) correlations were seen between spasticity and functioning scores. Correlations between spasticity and HRQL were generally weak (r < 0.5). Hemiparetic patients without spasticity had significantly better functioning scores and significantly better HRQL on 1 of the 8 SF-36 health scales (physical functioning) than patients with spasticity.

CONCLUSIONS

Few patients displayed spasticity 18 months after stroke. Spasticity might contribute to impairment of movement function and to limitation of activity, but seems to have a less pronounced effect on HRQL.

Outcome and Use of Health Care in Patients with Moderate Impairment and Stroke in South Madrid and Southwest Stockholm

BACKGROUND

A comparison was performed on two groups of patients with acute stroke and moderate impairment recruited in south Madrid and southwest Stockholm, with particular focus on function, activity, health-related quality of life, and use of health care resources.

METHODS

In all, 27 Spanish and 38 Swedish patients were included; 5 to 10 days after stroke all patients were continent and independent in feeding, had a normal cognitive status, and impaired motor capacity or aphasia. Patients were evaluated at baseline and at 3 and 6 months after stroke using a standardized protocol; information on use of health care resources was also collected.

RESULTS

Stroke severity at baseline, function and activity at 6 months, and total use of rehabilitation were similar in both groups. The Madrid group showed: (1) lower levels of function and activity at baseline and health-related quality of life at 3 months; (2) shorter length of hospital stay and lower use of hospital-based rehabilitation; and (3) several-fold higher use of outpatient rehabilitation.

CONCLUSIONS

Differences of the organization of acute stroke care for patients with moderate impairment in south Madrid and southwest Stockholm, including the timing and distribution of rehabilitation services, were remarkable and plausible explanation for temporal differences in patient outcome.

Impairment in Guillain–Barré syndrome during the first 2 years after onset: a prospective study

OBJECTIVES

To provide a comprehensive description of impairment in patients with Guillain-Barre syndrome (GBS) in Sweden during the first 2 years after disease onset.

METHODS

In this prospective multi-centre study, 42 patients, mean age 52 years, were evaluated at 2 weeks, 2 months, 6 months, 1 year and 2 years. Evaluations made use of validated, reliable measures of muscle strength, grip strength, finger dexterity, balance, facial-muscle function, respiratory function, gait, motor performance and sensory examination, and included patients' own assessments of pain, fatigue and paraesthesia.

RESULTS

Mechanical ventilation was required in 21% of patients. At 2 weeks, 1 year and 2 years after GBS onset: 100%, 62% and 55% of patients had submaximal overall muscle strength; 98%, 38% and 31% subnormal grip strength; and 38%, 14% and 12% affected facial-muscle function. At the same time points, 62%, 10% and 7% of patients were unable to walk 10 m independently; and affected sensation was detected in 93%, 55% and 52%.

CONCLUSIONS

Recovery occurred mainly during the first year after onset. At 2 years, motor impairment and sensory impairment were each still detectable in more than 50% of patients. We conclude that residual impairment is significant, somatically widespread and, likely, persistent.

Spasticity after stroke: its occurrence and association with motor impairments and activity limitations

BACKGROUND AND PURPOSE

There is no consensus concerning the number of patients developing spasticity or the relationship between spasticity and disabilities after acute stroke. The aim of the present study was to describe the extent to which spasticity occurs and is associated with disabilities (motor impairments and activity limitations).

METHODS

Ninety-five patients with first-ever stroke were examined initially (mean, 5.4 days) and 3 months after stroke with the Modified Ashworth Scale for spasticity; self-reported muscle stiffness; tendon reflexes; Birgitta Lindmark motor performance; Nine Hole Peg Test for manual dexterity; Rivermead Mobility Index; Get-Up and Go test; and Barthel Index.

RESULTS

Of the 95 patients studied, 64 were hemiparetic, 18 were spastic, 6 reported muscle stiffness, and 18 had increased tendon reflexes 3 months after stroke. Patients who were nonspastic (n=77) had statistically significantly better motor and activity scores than spastic patients (n=18). However, the correlations between muscle tone and disability scores were low, and severe disabilities were seen in almost the same number of nonspastic as spastic patients.

CONCLUSIONS

Although spasticity seems to contribute to disabilities after stroke, spasticity was present in only 19% of the patients investigated 3 months after stroke. Severe disabilities were seen in almost the same number of nonspastic as spastic patients. These findings indicate that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance. Careful and continual evaluation to establish the cause of the patient's disabilities is essential before a decision is made on the most proper rehabilitation approach.

Functional outcome, rehabilitation use and length of hospital stay for stroke patients in south Madrid

BACKGROUND

Health status and use of resources by stroke patients in Spain are unknown.

METHODS

A total of 103 acute stroke patients resident in south Madrid, population 665,168, were seen in 1996 at a general hospital and three primary care centres and evaluated at 5-10 days, 3 and 6 months after stroke. Health outcomes and patterns of rehabilitation and hospital use by patient groups were studied using multivariate logistic regression.

RESULTS

The group receiving rehabilitation exhibited higher levels of impairment, disability and handicap at each time point, these differences decreasing with time, except in the distribution of walking ability which was unimodal in that group. Younger age, poor walking ability and motor capacity, pain on the paretic side and living with a spouse predicted use of rehabilitation; low level of education predicted a long hospital stay.

CONCLUSION

Rehabilitation for stroke in south Madrid was sparse and used mainly by young, severely affected patients.

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

OBJECTIVE

To describe the content of a programme involving early hospital discharge and continued rehabilitation at home after stroke.

DESIGN

Quantitative and qualitative descriptive study of an intervention within the context of a randomized controlled trial.

SETTING

Huddinge University Hospital, Stockholm, Sweden.

SUBJECTS

Forty-one patients, moderately impaired after stroke, rehabilitated by a team of six occupational, physical, and speech and language therapists.

RESULTS

The average duration of the programme was 14 weeks, the mean number of home visits 12, and the median total time consumption 23 hours and 20 minutes, of which face-to-face contact with the patient constituted 54%. The rehabilitation process was pursued by the patient and the therapist in partnership. Supported by the team the therapists incorporated a wider domain of activities than usual and left a considerable amount of the training to self-directed activities. The most common foci of the visits were speech and communication, ADL activities and ambulation. When planning the intervention the therapists paid attention to discrepancies between the desires and abilities of the patient on the one hand and environmental demands on the other - discrepancies detected through observation of the patient in the home environment.

CONCLUSIONS

The home environment offers therapists working in a team opportunities to adopt a behaviour that enables patients with moderate neurological impairments after stroke to resume responsibility and influence over their rehabilitation process, resulting in an individualized rehabilitation programme that varies in duration, content and frequency of home visits.

Use of healthcare, impact on family caregivers and patient satisfaction of rehabilitation at home after stroke in southwest Stockholm

We previously conducted a randomized controlled trial in which early supported discharge from the Department of Neurology at Huddinge Hospital in southwest Stockholm with continuity of rehabilitation at home (n = 41) was compared to routine rehabilitation services (n = 40) for moderately disabled selected stroke patients. No statistical significant differences were found in patient outcome at 3 or 6 months, but a moderately positive effect in the home rehabilitation group was suggested. In the present study we evaluated resource utilization of health and social care, impact on family caregivers during 6 months after acute stroke and patient satisfaction. A 50% reduction in total hospitalization (initial and recurrent) was observed, from 30 days in the routine rehabilitation group to 15 days in the home rehabilitation group (p < 0.001). After discharge, the mean number of home visits in the home rehabilitation group was 12. In total, the routine rehabilitation group had a higher frequency of therapy contacts and daycare in outpatient care. Seventy-eight percent received help from a family caregiver in activities of daily living, yet only 15% had formal home help service. No major differences were found in use of home help service or impact on family caregivers in the form of time devoted to helping the patient or subjective well-being of spouses as per Sickness Impact Profile. Patient satisfaction was in favour of the home rehabilitation group, but a significant difference was only found in active participation in rehabilitation programme planning. In conclusion, early supported discharge with continuity of rehabilitation at home, using goal-directed functional activities based on the patient's personal interests, should be the rehabilitation service of choice for moderately disabled stroke patients fulfilling certain criteria, provided that further evaluation during the first year after stroke reveals no great changes in outcome or resource use. More research into the effectiveness and cost implications of early supported discharge with continuity of rehabilitation at home is needed in other parts of Sweden and in other countries before it can be asserted that the conclusions drawn from this study are applicable elsewhere.

Stroke patients in south Madrid: function and motor recovery, resource utilization, and family support

BACKGROUND AND PURPOSE

The purpose of the present study was to describe the epidemiology of stroke disability and the use of health resources in South Madrid.

METHODS

Among a population of 665 168 residents in South Madrid, patients with an acute stroke of clinical onset during March to July 1996 who were seen at a general hospital or at 1 of 3 primary care centers were evaluated at baseline (n=147) and at 3 months (n=110) and 6 months (n=112) after stroke. We assessed the frequencies of stroke and stroke-related residual disability per population unit, as well as the impairment, disability, secondary complications, use of health resources, and impact on quality of life.

RESULTS

In patients > or =60 years old, the incidence of stroke with severe residual disability after 6 months was 75 per 10 000, was higher in men, and increased with age; the proportion of survivors among those examined at baseline was 20%. The use of hospital days per population unit was similar to that of reported European data, but the use of other health care resources was less. Patients frequently used bladder and nasal catheters and presented with shoulder pain. Social activities were infrequent and decreased after stroke. Access to technical aids was limited, and home adaptations were exceptional. The impact of stroke on health-related quality of life among patients and main caregivers was modest.

CONCLUSIONS

The study shows that in South Madrid, (1) the use of health resources after stroke is low; (2) patients with stroke register low activities of daily living scores with a comparatively small impact on quality of life; and (3) relative to need, the use of rehabilitation, aids, and home adaptations and services was low.

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

PURPOSE

Stroke rehabilitation has received increased attention in the past decade. Recent trials with new alternatives such as home-based rehabilitation services are being conducted. The purpose of the study was to explore differences between a therapy session with a stroke patient in two different contexts, i.e. in the patient's home and in the hospital.

METHODS

The research design was a qualitative case study. Three data collection methods were used; participant observations of therapy sessions in two different contexts, semi-structured interviews and documents.

RESULTS

The data were examined and coded for common categories. Analysis of the data looking for similarities and differences in behaviour of two therapists and their patients during therapy sessions in the hospital and in the home was performed. The observations revealed that there was clearly a difference in behaviour; a different role-set used by the two therapists when working in the patient's home versus in the hospital. The major difference in patient behaviour was that the patient, observed in his home, took the initiative and expressed his goals, which was not the case with the patients observed in the hospital. The findings were confirmed in the interviews and the documents.

CONCLUSION

It is suggested that the context is a key component to be considered in the rehabilitation process of stroke patients.