Balance and mobility in patients with newly diagnosed Parkinson's disease - a five-year follow-up of a cohort in northern Sweden.

Background: The presence of early balance impairment in patients with Parkinson's disease has not been fully investigated.Purpose: The purpose of this study was to examine balance and mobility, self-perceived unsteadiness, self-reported falls, and effects of medication on balance among patients at their first visit to a neurological clinic and during the ensuing five years.Materials and methods: The participants were collected from a prospective longitudinal study. One hundred and forty-five patients with idiopathic Parkinson's disease and 31 healthy controls were included. The outcome measures were the Berg Balance Scale, the Timed Up and Go, the Postural Stability test and a questionnaire.Results: At their first visit to the neurological clinic, the patients performed less well on the Berg Balance Scale (p < 0.001, r = 0.36), the Timed Up and Go (p < 0.001, r = 0.32), and the Postural Stability test (p < 0.001, r = 0.35) compared with the controls. In addition, a higher percentage of the patients reported self-perceived unsteadiness (p < 0.001, phi = 0.47). During the ensuing five years, balance and mobility worsened both with and without medication (p < 0.01, r = 0.24-0.37), although with small median differences.Conclusions: Further studies are needed to confirm that minor balance impairments exist even at the time of diagnosis and worsen during the ensuing five years.IMPLICATIONS FOR REHABILITATIONImpairments in balance and mobility may occur early in Parkinson's disease, especially in the elderly patients, and seem to worsen during the first five years.There is a need to use sensitive outcome measures and to ask the patients about unsteadiness and falls to detect balance impairment in this cohort.Parkinsonian medication has a limited effect on balance and may preferably be complemented with balance exercises to target balance impairment early in Parkinson's disease.

Test-retest reliability of the twenty-five-hole peg test in patients who had a stroke.

OBJECTIVES: Weaknesses of the nine-hole peg test include high floor effects and a result that might be difficult to interpret. In the twenty-five-hole peg test (TFHPT), the larger number of available pegs allows for the straightforward counting of the number of pegs inserted as the result. The TFHPT provides a comprehensible result and low floor effects. The objective was to assess the test-retest reliability of the TFHPT when testing persons with stroke. A particular focus was placed on the absolute reliability, as quantified by the smallest real difference (SRD). Complementary aims were to investigate possible implications for how the TFHPT should be used and for how the SRD of the TFHPT performance should be expressed. DESIGN: This study employed a test-retest design including three trials. The pause between trials was approximately 10-120 s. PARTICIPANTS, SETTING AND OUTCOME MEASURE: Thirty-one participants who had suffered a stroke were recruited from a group designated for constraint-induced movement therapy at outpatient clinics. The TFHPT result was expressed as the number of pegs inserted. METHODS: Absolute reliability was quantified by the SRD, including random and systematic error for a single trial, SRD2.1, and for an average of three trials, SRD2.3. For the SRD measures, the corresponding SRD percentage (SRD%) measure was also reported. RESULTS: The differences in the number of pegs necessary to detect a change in the TFHPT for SRD2.1 and SRD2.3 were 4.0 and 2.3, respectively. The corresponding SRD% values for SRD2.1 and SRD2.3 were 36.5% and 21.3%, respectively. CONCLUSIONS: The smallest change that can be detected in the TFHPT should be just above two pegs for a test procedure including an average of three trials. The use of an average of three trials compared with a single trial substantially reduces the measurement error. TRIAL REGISTRATION NUMBER: ISRCTN registry, reference number ISRCTN24868616.

Walking on treadmill with Rett syndrome-Effects on the autonomic nervous system.

People with Rett syndrome have deficient central autonomic control, which may interfere with walking. We have limited knowledge regarding the effects of exertion during physical activity in Rett syndrome. The aim was to investigate the autonomic responses during walking on a treadmill in Rett syndrome. Twenty-six females, 12 with Rett syndrome and 14 healthy females were included. All individuals started on the treadmill by standing still, followed by walking slowly with progressive speed until reaching maximum individual speed, which they kept for 6 min. Heart rate (HR), systolic (SBP), diastolic (DBP), mean arterial blood pressures (MAP), cardiac vagal tone (CVT), cardiac sensitivity to baroreflex (CSB), transcutaneous partial pressures of oxygen (pO2), carbon dioxide (pCO2), and breathing movements were recorded simultaneously and continuously. Autonomic responses were assessed by MAP, CSB and CVT during walking at 3 and 6 min. The changes in CSB and CVT in people with Rett syndrome compared to controls indicated more arousal, but only when the treadmill was started; as they continued walking, the arousal dropped to control level. People with Rett syndrome exhibited little changes in pCO2 whereas the controls showed increased values during walking. This suggests poor aerobic respiration in people with Rett syndrome during walking. Five people with Rett syndrome had Valsalva type of breathing at rest, three of those had normal breathing while walking on the treadmill while the remaining two started but soon stopped the Valsalva breathing during the walk. Our results show that individuals with Rett syndrome can walk for up to 6 min at their own maximum sustainable speed on a treadmill. Energy production may be low during walking in Rett syndrome, which could cause early tiredness. A treadmill can be used in people with Rett syndrome, but must be introduced slowly and should be individually tailored. We propose that walking promotes regular breathing in Rett syndrome.

Is better preservation of eccentric strength after stroke due to altered prefrontal function?

Ventrolateral prefrontal cortex (VLPFC) is part of a network that exerts inhibitory control over the motor cortex (MC). Recently, we demonstrated that VLPFC was more activated during imagined maximum eccentric than during imagined concentric contractions in healthy participants. This was accompanied with lower activation levels within motor regions during imagined eccentric contractions. The aim was to test a novel hypothesis of an involvement of VLPFC in contraction mode-specific modulation of force. Functional magnetic resonance imaging was used to examine differences in VLPFC and motor regions during the concentric and the eccentric phases of imagined maximum contractions in a selected sample of subjects with stroke (n = 4). The subjects were included as they exhibited disturbed modulation of force. The previously demonstrated pattern within VLPFC was evident only on the contralesional hemisphere. On the ipsilesional hemisphere, the recruitment in VLPFC was similar for both modes of contractions. The findings support a hypothesis of the involvement of VLPFC in contraction mode-specific modulation of maximum force production. A disturbance of this system might underlie the lack of contraction mode-specific modulation commonly found among stroke subjects, often expressed as an increased ratio between eccentric and concentric strength.

Low-load/high-repetition elastic band resistance training in patients with COPD: a randomized, controlled, multicenter trial.

BACKGROUND AND AIMS: High-repetitive resistance training (RT) is recommended to increase peripheral muscular endurance in healthy adults; however, the effects of RT with this design on exercise capacity and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD) is unknown. The study aimed to investigate if low-load/high-repetition elastic band RT could improve functional capacity, muscular function, endurance cycle capacity or HRQOL in patients with COPD. METHODS: A prospective, randomized, controlled, multicentre trial was constructed with concealed allocation, blinded outcome assessment and intention-to-treat analysis. A total of 44 patients with moderate-to-very-severe COPD (forced expiratory volume during the first second, 44.6% predicted) were included. Patients were randomized to either the experimental group receiving 8 weeks of RT (three sessions/week) in combination with patient education (four occasions) or the control group receiving the patient education alone. RESULTS: At post-tests, the between-group differences were in favor of the experimental group on the 6-min walk test [mean difference (95% confidence interval)]: 34 m (14-54) and the 6-min pegboard and ring test [20 rings (3-37)]. No difference between groups was found on the chronic respiratory disease questionnaire [0.1 (-0.2 to 0.4)]. On secondary outcomes, results were in favor of the experimental group regarding upper extremity endurance capacity, muscular function and depression, but no difference was seen between groups on endurance cycle capacity and HRQOL. CONCLUSION: RT can increase functional capacity and muscular function but not cycle endurance capacity and HRQOL in patients with moderate-to-severe COPD.

Normal reactions to orthostatic stress in Rett syndrome.

The aim of this study was to investigate orthostatic reactions in females with Rett syndrome (RTT), and also whether the severity of the syndrome had an impact on autonomic reactions. Based on signs of impaired function of the central autonomic system found in RTT, it could be suspected that orthostatic reactions were affected. The orthostatic reactions in 21 females with RTT and 14 normally developed females matched by age were investigated when they rose from a sitting position, and during standing for 3 min. Reactions of the heart, the blood pressure and the time for recovery of systolic blood pressure, were studied in real time, heartbeat by heartbeat, simultaneously. There was no difference between participants with RTT and the normally developed controls regarding general orthostatic reactions (heart rate, systolic and diastolic blood pressure, and mean arterial pressure) when getting up from a sitting position, and when standing erect for 3 min. In the specific immediate response by the heart to standing up, the 30:15 ratio, significantly lower values were found for females with RTT. In the RTT group, the maximum fall of systolic blood pressure showed a tendency to a larger decrease, and the initial decrease in systolic blood pressure was significantly faster. The time for recovery of systolic blood pressure from standing erect did not differ between groups. At baseline the females with RTT had significantly lower systolic blood pressure and a tendency to a higher heart rate. The results do not indicate any autonomic limitations for people with RTT in getting up from a sitting position and standing. The participants with RTT had normal orthostatic reactions indicated by the heart and blood pressure responses when standing erect for 3min. A faster initial drop in systolic blood pressure in people with RTT was notable.

Assessing the effect of high-repetitive single limb exercises (HRSLE) on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease (COPD): study protocol for randomized controlled trial.

BACKGROUND: Single-limb knee extension exercises have been found to be effective at improving lower extremity exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Since the positive local physiological effects of exercise training only occur in the engaged muscle(s), should upper extremity muscles also be included to determine the effect of single limb exercises in COPD patients. TRIAL DESIGN: a prospective, assessor-blind, block randomized controlled, parallel-group multicenter trial. PARTICIPANTS: stage II-IV COPD patients, > 40 years of age, ex-smokers, with stable medical treatment will be included starting May 2011. Recruitment at three locations in Sweden. INTERVENTIONS: 1) high-repetitive single limb exercise (HRSLE) training with elastic bands, 60 minutes, three times/week for 8 weeks combined with four sessions of 60 minutes patient education, or 2) the same patient education alone. OUTCOMES: Primary: determine the effects of HRSLE on local muscle endurance capacity (measured as meters walked during 6-minute walk test and rings moved on 6-minute ring and pegboard test) and quality of life (measured as change on the Swedish version of the Chronic Respiratory Disease Questionnaire). Secondary: effects on maximal strength, muscular endurance, dyspnea, self-efficacy, anxiety and depression. The relationship between changes in health-related variables and changes in exercise capacity, sex-related differences in training effects, feasibility of the program, strategies to determine adequate starting resistance and provide accurate resistance for each involved movement and the relationship between muscle fatigue and dyspnea in the different exercise tests will also be analyzed. Randomization: performed by a person independent of the recruitment process and using a computer random number generator. Stratification by center and gender with a 1:1 allocation to the intervention or control using random block sizes. Blinding: all outcome assessors will be blinded to group assignment. DISCUSSION: The results of this project will contribute to increase the body of knowledge regarding COPD and HRSLE.

Patients' experiences of telerehabilitation at home after shoulder joint replacement.

We investigated the experience of ten patients who received video-based physiotherapy at home for two months after a shoulder joint replacement. Videoconferencing took place via the patient's home broadband connection at a bandwidth of 256-768 kbit/s. Qualitative interviews were carried out, transcribed and analysed. Through qualitative content analysis six categories were identified: (1) a different reinforced communication; (2) pain-free exercising as an effective routine; (3) from a dependent patient to a strengthened person at home; (4) closeness at a distance; (5) facilitated daily living; and (6) continuous physiotherapy chain. The access to bodily knowledge, continuity, collaboration and being at home were all aspects that contributed to the patients' recovery. The patients described experiences of safety, and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgement about each patient; this could be one reason for the positive findings. Home video-based physiotherapy may be useful in other kinds of physiotherapy.

What is the benefit of a high-intensive exercise program on health-related quality of life and depression after stroke? A randomized controlled trial.

The aim of the study was to evaluate the impact of a high-intensive exercise program containing high-intensive functional exercises implemented to real-life situations together with group discussions on falls and security aspects in stroke subjects with risk of falls. This was a pre-specified secondary outcome for this study. For evaluation, Short Form-36 (SF-36) health-related quality of life (HRQoL) and the Geriatric Depression Scale-15 (GDS-15) were used. This was a single-center, single-blinded, randomized, controlled trial. Consecutive >55 years old stroke patients with risk of falls at 3-6 months after first or recurrent stroke were randomized to the intervention group (IG, n = 15) or to the control group (CG, n = 19) who received group discussion with focus on hidden dysfunctions but no physical fitness training. The 5-week high-intensive exercise program was related to an improvement in the CG in the SF-36 Mental Component Scale and the Mental Health subscale at 3 months follow-up compared with baseline values while no improvement was seen in the IG at this time. For the SF-36 Physical Component Scale, there was an improvement in the whole study group at 3 and 6 months follow-up compared with baseline values without any significant changes between the IG and CG. The GDS-15 was unchanged throughout the follow-up period for both groups. Based on these data, it is concluded that high-intensive functional exercises implemented in real-life situations should also include education on hidden dysfunctions after stroke instead of solely focus on falls and safety aspects to have a favorable impact on HRQoL.

Life satisfaction in younger individuals after stroke: different predisposing factors among men and women.

OBJECT: To describe self-reported life satisfaction of younger persons after stroke and to investigate differences between men and women and factors associated with life satisfaction. DESIGN: A cross-sectional study. METHODS: Subjects were all persons after stroke, aged 18-55 years, registered in the Swedish National Quality Register for Stroke Care. A questionnaire was completed by 1068 individuals 8-36 months after stroke. Perceived Life Satisfaction was measured with LiSat-9. RESULTS: Less than half of the participants were satisfied with life as a whole. For women, significant associations were found between not being satisfied with life as a whole and haemorrhage (odds ratio (OR) 4.00) as well as a deteriorated ability to concentrate (OR 2.11). For men, significant associations were found to be not having a significant other (OR 3.17), not working (OR 2.26) and deteriorated ability to concentrate (OR 2.04). CONCLUSION: There were different factors for being satisfied with life as a whole between men and women, indicating a need for a more gender-specific rehabilitation than is currently used. The impact that deteriorated ability to concentrate has on life satisfaction is an important finding that needs to be considered in the rehabilitation process of younger patients after stroke.

Perceived impaired physical and cognitive functions after stroke in men and women between 18 and 55 years of age--a national survey.

PURPOSE: We describe self-reported consequences for physical and cognitive functions, detect possible gender differences, and find factors that were associated with deteriorated physical function in younger stroke patients, independent in their personal activities of daily life. METHODS: This study involved all first ever stroke patients, aged 18-55 years, registered in the Swedish national quality register for stroke. A questionnaire was answered by 1068 patients 8-36 months after the stroke. Changes were sought in physical and cognitive functions as compared with the pre-stroke condition. RESULTS: Eight hundred and sixty-seven patients (83%) were independent in personal activities of daily life. Significant differences between men and women were found: deteriorated physical ability was reported by 56-71% of the men and 65-79% of the women; deteriorated cognitive function was reported by 48-57% of the men and 57-68% of the women. Many patients (70% men, 77% women) reported that they had received insufficient information about physical exertion. Significant associations were found between deteriorated physical function and deteriorated cognitive function as well as fear of physical exertion. CONCLUSIONS: Deterioration was found in physical and cognitive functions greater in women then in men. Insecurity regarding physical exertion existed indicating that younger stroke patients might need information directly aimed at physical functioning and more gender specific than today. This study has raised the awareness that there also might be gender differences in other fields, which needs further studies.

Positive attitudes and preserved high level of motor performance are important factors for return to work in younger persons after stroke: a national survey.

OBJECTIVE: Significant numbers of younger persons with stroke should be given the opportunity to return to work. The aim of this study was to investigate factors of importance for return to work among persons after first ever stroke, in the age range 18-55 years. METHODS: A questionnaire was sent to all persons who had experienced a first ever stroke, 18-55 years of age, registered in the Swedish national quality register for stroke care, Riks-Stroke. Of the 1068 who answered the questionnaire, 855 (539 men and 316 women) were in paid employment before their stroke, and were included in this study. RESULTS: Sixty-five percent returned to work and, of these, an equal proportion were men and women. Significant factors associated with return to work were the perceived importance of work (odds ratio (OR) 5.10), not perceiving themselves as a burden on others (OR 3.33), support from others for return to work (OR 3.66), retaining the ability to run a short distance (OR 2.77), and higher socioeconomic codes (OR 2.12). A negative association was found between those rehabilitated in wards intended for younger persons and return to work (OR 0.37). CONCLUSION: External support from others, and positive attitudes towards return to work, were factors associated with successful return to work after stroke. Contrary to what was expected, independence in personal activities of daily living and cognitive factors were not associated with return to work to the same extent as persistent higher level of physical functions, such as ability to run a short distance.

Physiotherapy at a distance: a controlled study of rehabilitation at home after a shoulder joint operation.

We explored the benefit of video communication in home rehabilitation after shoulder joint replacement and compared it to referral for physiotherapy in the conventional way. A total of 22 patients were included in the study. The intervention group (n = 10) had training at home under the supervision of a physiotherapist at the hospital using videoconferencing. The control group (n = 12) had physiotherapy training in a conventional way in their home town. All patients had the same postoperative, three-phase-programme for two months. The outcome measures were a Visual Analogue Scale (VAS) for pain, range of motion (ROM), shoulder function ability (Constant score and SRQ-S) and health-related quality of life (SF-36). Questions about areas of priority for improvement and general satisfaction with the shoulder were also included. The telemedicine group received a greater number of treatments compared to the control group. After the intervention, there were significant improvements in VAS-pain, Constant score and SRQ-S for both groups. The telemedicine group improved significantly more in all three measurements than the control group (P < 0.001 for all). When changes from baseline to follow-up were compared, the telemedicine group improved significantly more in terms of decrease in pain (P = 0.004) and vitality (P = 0.001) than the control group. Despite some limitations, there seem to be clear benefits from physiotherapy at a distance with a telemedicine technique that allows patients to obtain access to physiotherapy at home.

Thigh muscle strength and endurance in patients with COPD compared with healthy controls.

The aim of this study was to evaluate thigh muscle strength and endurance in patients with COPD compared with healthy controls. Forty-two patients (26 women; 16 men) with moderate to severe COPD and 53 (29 women; 24 men) age-matched healthy controls participated in the study. The subjects were tested for maximum voluntary contractions (MVC), endurance and fatigue of the thigh muscles on an isokinetic dynamometer (KinCom). Endurance was expressed as the number of attained repetitions of knee extension and muscle fatigue as a fatigue index (FI). MVC in knee extension was 17% lower in female patients (P=0.017) but no difference was found in male patients (P=0.56) compared to controls. MVC in knee flexion was lower both in female (51%) (P<0.001) and male patients (40%) (P<0.001) compared to controls. Both female and male patients had significantly lower muscle endurance compared to controls. Female patients had a higher FI (22.5%) than female controls (10%) (P=0.001) while no difference was found regarding FI between male patients (15%) and male controls (10%) (P=0.103). The level of self-reported everyday physical activity did not differ between groups. The results showed impaired skeletal muscle function in COPD, except for MVC in knee extension in male patients. Female patients seemed to be more prone to decrease in thigh muscle function. More focus on improving muscle strength and muscle endurance should be considered when designing pulmonary rehabilitation programs. Patients with preserved level of physical activity can be included in exercise programs and gender-related differences should be taken into account.

Rett syndrome from a family perspective: The Swedish Rett Center survey.

The aim of this study was to make a description of the early development in individuals with the diagnosis Rett syndrome using parents' information. Information received from 125 cases of Rett syndrome in Sweden in 1997 provided us with families' description of early development in gross motor function, fine motor function and communication/social interplay. Best abilities before regression were presented, 62% lost their best abilities, 22% kept them and 5% kept them with deterioration. Seventy-three percent learnt to walk, 20% stopped walking and 2% retrained walking. Concerning feeding, 69% learnt to feed themselves, 57% lost this ability, 7% retrained the ability and 5% learnt to feed after regression. Sixty-four percent were one year or younger when there was a deviation in development. Sixty answers reported the girl was late in developing functions while 35 reported sudden loss of reached abilities. Seventy-four percent developed a scoliosis and 83% reported other deformities; of these, deformities in feet were the most common. Postural control was poor since all but 15 girls/women learnt in different directions when sitting. Transitional movements were difficult to perform. In 80% of cases, the families were those who suspected early that something was wrong in the child's development. Because of this it is essential that medical staff is aware of the different ways RS develops in order to give families early appropriate support and a plan for intervention. Since there is not only loss of function in this group but also kept abilities, retrained abilities and abilities achieved after regression, more research has to be focused on management and treatment to help persons with Rett syndrome keep and develop abilities according to their individual resources.

Cardiac rehabilitation for the elderly: Qi Gong and group discussions.

BACKGROUND: Over the last decade several studies have shown that patients with coronary artery disease even above the age of 70 can be successfully treated with advanced medical and surgical methods. Unfortunately, rehabilitation programmes for this group are rarely offered. It is important to develop forms of rehabilitation that are adapted to the specific needs of this increasing group of elderly patients. The aim of this randomized study was to investigate whether the combination of Qi Gong and group discussions would increase physical ability for elderly patients > or =73 years with coronary artery disease. METHODS: A total of 95 patients (66 men and 29 women), with documented coronary artery disease, were randomized to an intervention group (n=48) mean age 77+/-3 (73-82) or to a control group (n=47) mean age 78+/-3 (73-84). The intervention groups met weekly over 3 months. The control group got usual care. Physical ability was assessed at baseline and after the intervention. RESULTS: Patients in the intervention group increased their self-estimated level of physical activity (P=0.011), and their performance in the one-leg stance test for the right leg (P=0.029), co-ordination (P=0.021) and the box-climbing test for right leg (P=0.035). CONCLUSION: A combination of Qi Gong and group discussions appear to be a promising rehabilitation for elderly cardiac patients in terms of improving self-reported physical activity, balance and co-ordination. This could be an option for elderly patients who do not participate in the ordinary cardiac rehabilitation.

Frustrated and invisible--younger stroke patients' experiences of the rehabilitation process.

PURPOSE: This study aimed to get knowledge of the younger stroke patient's viewpoint and to describe how young stroke patients experience the rehabilitation process. The purpose was also to develop hypotheses about the relationship between young stroke patients and the rehabilitation process. METHOD: Thematised in-depth interviews were performed with two women and three men who suffered from stroke (37 - 54 years). The analysis used was the Grounded Theory method of constant comparison. RESULTS: The analyses resulted in the core category 'Frustration' which was derived from the categories labelled 'The paralysed everyday' and 'Outside and invisible'. 'The paralysed everyday' category involved different aspects of everyday life after a stroke. Because of their fatigue they were unable to work and their family and social life were negatively affected. They found it difficult to engage in daily life activities and felt indifferent. The three women expressed frustration over the demands they experienced as being mothers and housekeepers, whereas the two men emphasised economic responsibility of the family as problematic. The category 'Outside and invisible' describes the lack of participation the informants experienced regarding the rehabilitation process. The informants felt they lacked information and age-adapted interventions. Their needs were not provided for and they felt distant from the other patients. Their remaining symptoms were probably on a cognitive basis and therefore invisible. This was a source of frustration. CONCLUSION: The hypotheses generated indicated that young stroke patients are frustrated and invisible due to the fact that the rehabilitation setting does not acknowledge the different needs of young stroke patients compared with older patients.