How do multimorbidity and lifestyle factors impact the perceived health of adults with intellectual disabilities?

BACKGROUND

Adults with intellectual disability (ID) have poorer physical and perceived health than the general population. Knowledge of perceived health predictors is both limited and important for guiding the development of preventive actions. The aims of this study were to investigate (1) the associations between perceived health and demographics, degree of ID, physical health conditions, and weight and physical activity level and (2) lifestyle factors and multimorbidity as predictors for perceived health adjusted for age, gender, and level of ID.

METHOD

The North Health in Intellectual Disability study is a community based cross-sectional survey. The POMONA-15 health indicators were used. Univariate and multivariate logistic regression analyses with poor versus good health as the dependent variable were applied.

RESULTS

The sample included 214 adults with a mean age 36.1 (SD 13.8) years; 56% were men, and 27% reported perceiving their health as poor. In univariate analyses, there were significant associations between poor health ratings and female gender, lower motor function, number of physical health conditions and several indicators of levels of physical activity. In the final adjusted model, female gender [odds ratio (OR) 2.4, P < 0.05], level of ID (OR 0.65, P < 0.05), numbers of physical health conditions (OR 1.6, P < 0.001) and lower motor function (OR 1.5 P < 0.05) were significant explanatory variables for poor perceived health, with a tendency to independently impact failure to achieve 30 min of physical activity daily (OR 2.0, P = 0.07).

CONCLUSION

Adults with ID with female gender, reduced motor function and more physical health conditions are at increased risk of lower perceived health and should be given attention in health promoting interventions. A lack of physical activity tends to negatively influence perceived health.

Measurement Properties of the Nordic Questionnaire for Psychological and Social Factors at Work: A Rasch Analysis

The main aim of this study was to evaluate the measurement properties of the Nordic Questionnaire for Psychological and Social Factors at Work (QPS Nordic) and the domains of demand, control and support. The Rasch analysis (RUMM 2030) was based on responses from 226 subjects with back pain who completed the QPS Nordic dimensions of demand, control, and social support (30 items) at one year follow up. The Rasch analysis revealed disordered thresholds in a total of 25 of the 30 items. The domains of demand, control and support fit the Rasch model when analyzed separately. The demand domain was well targeted, whereas patients with current neck and back pain had lower control and higher support than reflected by the questions. Two items revealed DIF by gender, otherwise invariance to age, gender, occupation and sick-leave was documented. The demand, control support domains of QPS Nordic comprised unidimensional constructs with adequate measurement properties.

Validation of the Brief ICF core set for low back pain from the Norwegian perspective

AIM

The aim of this study was to identify candidate categories from the International Classification of Functioning, Disability and Health (ICF) to be included in the Brief ICF Core Set for low back pain (LBP) by examining their relation to general health and functionality.

METHODS

This was part of an international multicentre study with 118 participating Norwegian patients with LBP. The Comprehensive ICF Core Set for LBP was filled in by health professionals. The patients reported their health-related quality of life in the Medical Outcome Study Short Form 36 (SF-36) and function in the Oswestry Disability Index. Two questions regarding the patient's general health and functioning were completed by the health professionals and the patients themselves. Regression models were developed in order to identify ICF categories explaining most of the variance of the criterion measures.

RESULTS

Twelve ICF categories remained as significant explanatory factors according to the eight regression models, four of which were not included in a previously proposed Brief ICF Core Set for LBP.

CONCLUSIONS

The present study complements the development of the Brief ICF Core Set for LBP, and indicates a minimum number of categories needed to explain LBP patients' functioning and health. Further elaboration of the Brief ICF Core Set for LBP with multinational data is needed.

Functional outcome and health-related quality of life 10 years after moderate-to-severe traumatic brain injury

OBJECTIVES

To describe the functional outcome and health-related quality of life (HRQL) 10 years after moderate-to-severe traumatic brain injury (TBI).

MATERIAL AND METHODS

A retrospective, population-based study of 62 survivors of working-age with moderate-to-severe TBI injured in 1995/1996, and hospitalized at the Trauma Referral Center in Eastern Norway. Functional status was measured by the Glasgow Outcome Scale-Extended (GOS-E). HRQL was assessed by the SF-36 questionnaire.

RESULTS

The mean current-age was 40.8 years. The frequency of epilepsy was 19% and the depression rate 31%. A majority had good recovery (48%) or moderate disability (44%). Employment rate was 58%. Functional and employment status were associated with initial injury severity in contrast to HRQL. Study patients had significantly lower scores in all SF-36 dimensions when compared with the general Norwegian population.

CONCLUSION

At 10-years follow-up, our study population is still in their most productive years and affected domains should be considered in long-term follow-up and intervention programs.

Does the International Classification of Functioning, Disability and Health (ICF) core set for low back pain cover the patients' problems? A cross-sectional content-validity study with a Norwegian population

AIM

The aim of this work was to evaluate the Norwegian form of the International Classification of Functioning, Disability and Health (ICF) Core Set for low back pain patients and investigate the feasibility of the Core Set in clinical practice.

METHODS

This was part of an international multicenter study with 118 participating Norwegian patients referred to Departments of Physical Medicine and rehabilitation with low back pain (LBP). The ICF Core Set for LBP was filled in by the health professionals. The patients reported their problems using the Medical Outcome Study Short Form 36 (SF-36) and the Oswestry Low Back Pain Disability Questionnaire (ODI).

RESULTS

The ICF Core Set categories capture the problems of the LBP patients, and few categories were reported to be missing. Many problems were reported within body function, and problems within work and employment were captured by the activity and participation component. The environmental factors in ICF were most frequently scored as facilitators, but the same factor could also represent a barrier in other individuals. Health professionals, family and friends were important factors within this domain. Few problems were scored as severe or complete indicating the need of collapsing the qualifier levels. Scoring of the ICF Core Set was feasibly, but rather time-consuming.

CONCLUSION

The ICF Core Set for LBP captures the problems of LBP, and adds important aspects to clinical practice in the field of LBP. However, the ICF Core Set for LBP needs further elaboration in order to improve the clinical feasibility.

Early supported discharge of patients with acute stroke: a randomized controlled trial

PURPOSE

To evaluate the feasibility and effectiveness of early supported discharge (ESD) following acute stroke.

METHOD

An ESD scheme was compared to conventional rehabilitation in a randomized controlled trial. All patients admitted with acute stroke were considered for inclusion. Eighty-eight (20.2%) were found to be eligible and 82 were randomized either to early supported discharge (n = 42) or conventional rehabilitation (n = 40). The primary outcome measure was the Nottingham Extended Activities of Daily Living Scale. The General Health Questionnaire, the Montgomery Aasberg Depression Rating Scale, mortality, placement and patient and career satisfaction served as secondary outcome measures.

RESULTS

Median length of stay was reduced from 31 days in the conventional hospital rehabilitation group to 22 days in the early supported discharge group (p = 0.09). No differences were found regarding primary outcome. The General Health Questionnaire score showed a significant difference in favour of the early supported discharge group at three months (19.5/24, p = 0.02), but not at six. At six months, the proportion of patients being dead or in institution showed a trend of being higher in the conventional rehabilitation group (OR 3.8, 95% CI 0.8-23).

CONCLUSIONS

Early supported discharge after stroke is feasible and it is possible that it has benefits compared with conventional rehabilitation.

Acute phase predictors of subsequent psychosocial burden in carers of elderly stroke patients

The objective was to describe the psychosocial burden experienced by informal carers of elderly stroke victims, and to identify its predictors among baseline characteristics of the patients. From a prospective study of 171 elderly stroke patients admitted to a geriatric ward for rehabilitation in the acute phase, 68 patients living at home with a primary caregiver were identified 6 months after the stroke. At baseline, all the patients were assessed with respect to motor function, cognitive function, global handicap and activities of daily living, and after 6 months the caregivers were assessed, using the Relatives' Stress Scale. According to this, the most frequent impacts were worries that an accident might befall their relatives, that they had to reorganise their household routines and further, that their social life and ability to take holidays had been reduced. Impaired cognitive function was the only baseline patient characteristic that predicted a subsequent psychosocial burden on the carer. Special attention should be paid to elderly stroke patients initially assessed with impaired cognitive function and their caregivers.

Inter-rater reliability of the Sødring Motor Evaluation of Stroke patients (SMES)

The Sødring Motor Evaluation of Stroke patients is an instrument for physiotherapists to evaluate motor function and activities in stroke patients. The rating reflects quality as well as quantity of the patient's unassisted performance within three domains: leg, arm and gross function. The inter-rater reliability of the method was studied in a sample of 30 patients admitted to a stroke rehabilitation unit. Three therapists were involved in the study; two therapists assessed the same patient on two consecutive days in a balanced design. Cohen's weighted kappa and McNemar's test of symmetry were used as measures of item reliability, and the intraclass correlation coefficient was used to express the reliability of the sumscores. For 24 out of 32 items the weighted kappa statistic was excellent (0.75-0.98), while 7 items had a kappa statistic within the range 0.53-0.74 (fair to good). The reliability of one item was poor (0.13). The intraclass correlation coefficient for the three sumscores was 0.97, 0.91 and 0.97. We conclude that the Sødring Motor Evaluation of Stroke patients is a reliable measure of motor function in stroke patients undergoing rehabilitation.

Association between impairments, self-care ability and social activities 1 year after stroke

PURPOSE

To explore how motor and cognitive impairments relate to physical activities of daily living (PADL) and social activities after stroke.

METHOD

The data related to 65 patients (mean age 74.4 years, 43% females), assessed 1 year after stroke by means of the Sødring Motor Evaluation of Stroke patients and the Assessment of Stroke and other Brain damage instruments. The self-care and social activities scales applied were the Barthel ADL Index and the Frenchay Activities Index (FAI). The association between impairment variables on the one hand and PADL and FAI scores on the other was estimated using Kendall rank correlations.

RESULTS

Arm motor function correlated most strongly with the Barthel score (tau = 0.76), and visuospatial function came second (tau = 0.58). Factor analysis of the FAI produced three subscales: a 'domestic' factor most strongly related to arm motor function (tau = 0.49); 'outdoor' related to visuospatial ability (tau = 0.48); and 'hobby' which had no significant correlates.

CONCLUSION

In the chronic phase of stroke, self-care and involvement in social activities relate most strongly to arm motor function and visuospatial ability. Outdoor activities depend mainly on visuospatial function.

Predictors of outcome of rehabilitation of elderly stroke patients in a geriatric ward

PURPOSE

To identify predictors of outcome after 12 months in elderly stroke patients rehabilitated in a geriatric ward.

DESIGN

Prospective with evaluation in the subacute phase and after 12 months.

SETTING

Geriatric ward and outpatient clinic.

SUBJECTS

All stroke patients admitted from the acute unit to a geriatric ward for rehabilitation during a 16-month period (n = 171).

MAIN OUTCOME MEASURES

Place of living, mortality and social functioning (Frenchay Activities Index) 12 months following stroke.

RESULTS

Age, urinary incontinence and cognitive function were significantly associated with place of living (home versus nursing home) 12 months post stroke in bivariate analyses. However, using multivariate logistic regression analyses, only age (p = 0.005) and urinary incontinence at baseline (p = 0.028) remained independent predictors of place of living. Mortality during the first year was significantly predicted by urinary incontinence and gender (men doing worse), whereas the Barthel Activities of Daily Living (ADL) Index sumscore was the only significant independent predictor of social activities.

CONCLUSION

Urinary incontinence at baseline seems to be a most important predictor of outcome 12 months post stroke in geriatric patients. However, with regard to social activities (Frenchay Activities Index), functional impairment in the initial phase as reflected by the Barthel ADL Index supersedes other predictors.

Screening by nurses for aphasia in stroke--the Ullevaal Aphasia Screening (UAS) test

PURPOSE

In Norway, the speech therapist is responsible for the assessment of language impairment after stroke, but many hospitals have no speech therapist. This study therefore developed and evaluated a simple method to be used by nurses to detect aphasia in the acute stage of stroke; the Ullevaal Aphasia Screening (UAS) test.

METHOD

The study was carried out among 37 stroke patients admitted to an acute stroke unit. They were assessed by nurses using the UAS, while the results of a comprehensive assessment by a speech therapist acted as the 'gold standard'.

RESULTS

The predictive value of a positive test was 0.67 and that of a negative test 0.93; only two out of 28 who screened negative on the UAS were diagnosed with mild aphasia by the speech therapist. The weighted kappa coefficient of agreement was 0.83, indicating a strong agreement between the nurses' and speech therapists' scoring. The screening took 5-15 minutes to complete.

CONCLUSION

The Ullevaal Aphasia screening test seems to be a short and valid screening instrument for aphasia in the acute stage of stroke, but further studies would be needed to substantiate the efficacy of the UAS test.

Validation of the screening instrument for neuropsychological impairment in stroke

BACKGROUND AND PURPOSE

Full neuropsychological assessment is time-consuming and exhausting for the patient in the early phase of stroke. The screening instrument for neuropsychological impairment in stroke (SINS) is a brief, bedside-applicable instrument designed to screen perceptual and cognitive dysfunction related to functional activities in stroke. It has been developed by physiotherapists to be incorporated in the general assessment of the patient. This study evaluates the validity of the method against a more extensive reference method assessing cognitive function.

METHODS AND RESULTS

An unselected group of hospitalized stroke patients (N = 87) was assessed 10 days and 12 months after stroke. Factor analyses (52% explained variance), identified three factors: 'aphasia', 'apraxia' and 'visuocognitive dysfunction'. Receiver operating characteristics (ROC) curves demonstrated that for all factors, high specificity was maintained at the high sensitivity needed for a screening method. Kendall rank correlation coefficients between the scorings on the new instrument and the reference method were high. Effect size analysis showed that the ability of the new instrument to detect change in cognitive functioning during the first year was of the same magnitude as the reference method.

CONCLUSIONS

SINS has a high sensitivity regarding cognitive dysfunction, as diagnosed by the more comprehensive and time-consuming reference method. The instrument would be useful as an initial step in the assessment of neuropsychological impairment in stroke patients.

[Rehabilitation of elderly stroke patients in a geriatric department. Course and prognosis]

Stroke is an age-related disorder where nearly 70% of the patients are over 70 years of age. More knowledge about the outcome and prognosis among the eldest stroke victims is needed. We studied 171 elderly stroke patients admitted to geriatric wards for rehabilitation. The patients were assessed on admittance to and discharge from hospital, and six and 12 months after the stroke. The mean age was 78.4 years. During the first year, 19% died and 25% were admitted to nursing homes. After 12 months six out of ten patients were living at home. Our results indicate that even elderly stroke patients have a potential for functional improvement after a stroke.

[Prognosis one year after hip fracture]

This study evaluates the demography and health in a hip fracture population, and predictors of outcome one year after the fractures occurred. Physical, mental and social functioning in 109 patients who were referred from home with hip fractures were assessed retrospectively; during the hospital stay, at discharge, and after 4 and 12 months. Mobility, Katz' ADL-index and a short-version of MMSE were used in assessing their physical and mental conditions. No essential changes were found in either demography or health. The most significant predictors of outcome were age, prefracture mobility and post-fracture mental status. The proportion of patients suffering from acute confusion was considerable. The result was a higher risk of mortality, institutionalisation and poor physical outcome. It is important to pay more attention to the prevention and treatment of cases involving acute confusion.

Are there gender differences in functional outcome after stroke?

PURPOSE

To study gender differences in functional outcome unexpectedly observed in a follow-up study of stroke patients.

DESIGN

Prospective study of hospitalized stroke patients, with evaluations in the subacute phase and after one year.

SETTING

Geriatric and general medical wards, and geriatric outpatient clinic of a university hospital serving as general hospital for a defined population.

SUBJECTS

All stroke patients admitted during a six-month period (n = 165) were considered for inclusion, of whom 87 could be assessed in the subacute phase and 65 after one year.

MAIN OUTCOME MEASURES

Motor function assessed by the Sødring Motor Evaluation of Stroke Patients; cognitive function by the Assessment of Stroke and other Brain Damage; and activities of daily living (ADL) function by the Barthel Index. Nursing-home residency registered after one year.

RESULTS

Men achieved a significantly better score than women on most of the scales used. The age-adjusted odds for a man to have a higher Barthel score than a woman was 3.1 (95% confidence interval (CI) 1.3-7.0) in the subacute phase and 3.3 (95% CI 1.2-9.0) after one year. Differences of the same magnitude were seen on the subscales of the motor and cognitive tests. The same trend was observed on all items of the Barthel Index. The males had a lower likelihood to be permanent nursing-home residents after one year, the age-adjusted odds ratio for nursing-home residency for females versus males being 6.3 (95% CI 1.2-65.3).

CONCLUSION

Women seem to be functionally more impaired by stroke than men.

Subjective well-being one year after stroke

OBJECTIVE

To compare the subjective well-being of stroke patients with that of a reference group, and to study its relationship to patient characteristics.

DESIGN

Cross-sectional study.

SETTING

Interviews performed in the respondents' homes, tests performed at the outpatient clinic.

SUBJECTS

Sixty patients one year after stroke (median age 74 years, interquartile range (IQR) 68-80), and 419 reference individuals (median age 75 years, IQR 71-80).

MEASURES

Subjective well-being assessed with the General Health Questionnaire (GHQ-20). Explanatory variables were demographic and medical characteristics of the individuals and scores on validated tests: Barthel Index, Frenchay Activities Index (FAI), Sødring Motor Evaluation of Stroke Patients, Assessment of Cerebral Stroke and other Brain Damage, and Mini-Mental State Examination (MMSE).

RESULTS

A significantly higher proportion of the stroke patients than of the controls rated their subjective well-being as low, also after adjustment for age and gender (adjusted odds ratio 20.1, 95% confidence interval 9.6-42.0 by logistic regression). In bivariate analyses, leg and arm motor impairment, visuospatial impairment, apraxia, aphasia, low Barthel score, low FAI score, low MMSE score, and institutionalization were highly significant predictors of low subjective well-being (p-values < 0.01). In multiple linear regression, a model with gender (p = 0.3) and upper extremity motor score (p < 0.01) fitted the data well, and explained 48% of the variance in GHQ.

CONCLUSION

Subjective well-being is decreased one year after stroke, and this is mainly attributed to arm motor impairments.

Predictive validity of the Sødring Motor Evaluation of Stroke Patients (SMES)

The Sødring Motor Evaluation of Stroke Patients (SMES) has been developed as an instrument for the evaluation by physiotherapists of motor function and activities in stroke patients. The predictive validity of the instrument was studied in a consecutive sample of 93 acute stroke patients, assessed in the acute phase and after one year. The outcome measures were: survival, residence at home or in institution, the Barthel ADL index (dichotomized at 19/20), and the Frenchay Activities Index (FAI) (dichotomized at 9/10). The SMES, scored in the acute phase, demonstrated a marginally significant predictive power regarding survival, but was a highly significant predictor regarding the other outcomes. The adjusted odds ratio for a good versus a poor outcome for patients in the upper versus the lower tertile of the SMES arm subscore was 5.4 (95% confidence interval 0.9-59) for survival, 11.5 (2.1-88) for living at home, 86.3 (11-infinity) for a high Barthel score, and 31.4 (5.2-288) for a high FAI score. We conclude that SMES has high predictive validity.

The Frenchay Activities Index in stroke patients: agreement between scores by patients and by relatives

The aim of the study was to compare stroke patients' own scorings of the Frenchay Activities Index with scorings based on interviews with their nearest relatives. Fifty-two patients and relatives were interviewed separately 1 year after the stroke. The mean sumscore based upon information from the patients was 29.0, and that based upon the relatives' replies was 27.7 (mean difference 1.4, 95% confidence interval (CI) -0.1 to 2.8). The Kendall tau B correlation between the two sumscores was 0.72 (95% CI 0.63 to 0.81). In half of the patients the two sumscores differed by four points or more, and in every fourth the two sumscores differed by six points or more. The weighted kappa for the single items varied between 0.36 and 0.89. No characteristics of patients or relatives were identified that were related to disagreement between the two scores.

Description and validation of a test of motor function and activities in stroke patients. The Sødring Motor Evaluation of Stroke Patients

A new method (The Sødring Motor Evaluation of Stroke Patients) has been developed for physiotherapists to evaluate motor function and activities in stroke patients. Its main characteristics are the assessment of motor activity without assisting the patient, and the use of a rating which reflects quantity as well as quality in motor performance. A hospitalised group of stroke patients (n = 93) was assessed three times after the acute event, by means of SMES. The data were analysed regarding construct validity as well as concurrent validity against another assessment method. Factor analyses showed a reasonably stable three-factor pattern ("arm", "gross motor function", and "leg") which explained 84, 89 and 90%, respectively, of the variance at the three study points, with Factor 1 ("arm") as the dominant factor. The ordinality of the rating scale was assessed by means of linear regression analysis and found to be acceptable. The correlation coefficients were high between comparable parts of the new and the reference methods.

The Barthel ADL index: factor structure depends upon the category of patient

The validity and reliability of the Barthel index were studied in 60 geriatric patients, 87 stroke patients, and 102 patients with hip fracture, using a factor analysis methodology which explicitly accounts for the ordinal nature of the scoring on each item. The findings substantiate that the Barthel index is unidimensional among stroke patients, but not among geriatric patients or patients with hip fracture. In the latter two groups, one factor related to mobility, the other to bodily functions. A sum-score to characterize geriatric and hip fracture patients does not take into account the complex structure of the Barthel index.

The Barthel ADL index one year after stroke: comparison between relatives' and occupational therapist's scores

The activities of daily living of 54 patients 1 year after stroke were rated with the Barthel Index by an occupational therapist (OT). A physician independently rated the same patients from interviews with their nearest relative. The mean sum-score obtained by the doctor was 16.7, while the mean sum-score obtained by the OT was 17.1. In more than 80% of the patients, the difference in sum-score was two points or less, which was considered to reflect acceptable agreement. Weighted kappa values of each item varied between 0.42 and 0.92, indicating moderate agreement for the items 'grooming' and 'bladder' and good or very good agreement for the other items. There was a statistically significant bias in the bladder item; the doctor's score being lower than that of the OT. The other items showed no significant bias. The probability of disagreement between the two raters increased with the patient's age; no other factors were found to be related to disagreement.

Oxygen uptake/heart rate relationship in leg and arm exercise, sitting and standing

The effect of leg exercise and of arm exercise in sitting and standing body positions on energy output and on some cardiorespiratory parameters was studied in seven male subjects. Oxygen uptake (VO2), heart rate (fH), pulmonary ventilation (VE) and respiratory frequency were measured at rest, in the 7-8th min of submaximal work (300, 600, 900 kpm/min), and at maximal effort. Significantly higher Vo2, fH, and VE in arm cranking than in cycling were found at submaximal work loads above 300 kpm/min. Though the maximal work load in arm exercise was 50-60% of that in cycling, Vo2 in arm work was at maximal effort only 22% lower than in leg exercise while the difference in fH was insignificant. No differences were found in arm work between the results obtained at any work level in sitting and standing body positions. The only postural difference in arm work was a 13% higher work load achieved at maximal effort when standing than when sitting. Differences in fH between arm and leg exercise were much smaller for the same Vo2 than for the same work load and were time dependent. While fH quickly leveled off in leg exercise, fH in arm cranking rose steadily during the first 6 min of work which created the fH differences observed in the 7-8 min of submaximal arm arm and leg exercise. At submaximal work levels a tendency to synchronize the respiratory frequency with the frequency of the rotatory movements was more apparent in arm cranking than in cycling.