Experiences of co-producing person-centred and cohesive clinical pathways in the national system for knowledge-based management in Swedish healthcare: a qualitative study.

BACKGROUND: When the 21 Swedish county councils decided to collaborate in the creation of a national system for knowledge-based management, patient participation was mandatory. Patient and next-of-kin representatives (PR) co-produced person-centred and cohesive clinical pathways together with healthcare professionals (HPR). Research on co-production in healthcare at the national level is scarce. The aim of this study is to explore experiences of patient participation from the perspectives of both PRs and HPRs when co-producing clinical pathways within the Swedish nationwide healthcare system for knowledge-based management. METHODS: A qualitative study was conducted. A strategic sample of nine PRs and eight HPRs were interviewed individually between August 2022 and January 2023 using a semi-structured interview guide. We analysed data using an inductive content analysis. RESULTS: Three main categories were identified: (1) Finding appropriate patient representativeness; (2) Working methods that facilitate a patient perspective; and (3) Influence of the patient perspective in the clinical pathways. CONCLUSIONS: The study demonstrates the importance of patient and next-of-kin participation in the construction of clinical pathways at the national level. The results provide a platform for further research on patient participation on the national level and add to studies on if and how patient participation on this level has an impact on how the clinical pathways are put into practice at the micro level, and the support provided at the meso level. The study contributes to the growing body of literature studying patient participation and co-production. TRIAL REGISTRATION: Region Örebro County ID 276,940. An advisory opinion was obtained from the Swedish Ethical Review Authority (2021-05899-01).

Exploring expectations and readiness for healthy lifestyle promotion in Swedish primary health care: a qualitative analysis of managers, facilitators, and professionals.

OBJECTIVE: Prior to a multifaceted implementation strategy for a healthy lifestyle-promoting practice the expectations of primary health care managers, appointed internal facilitators and health care professionals on supporting change was explored. DESIGN: This study had an explorative qualitative design using data gathered from individual interviews and focus groups. Qualitative content analysis with a deductive category development was applied using the Consolidated Framework for Implementation Research. SETTING AND PARTICIPANTS: The study was conducted in a primary care setting in central Sweden as a part of the Act in Time research project. Prior to a multifaceted implementation strategy, we held 16 individual interviews with managers and appointed facilitators and five focus groups with 26 health care professionals. RESULTS: Managers, facilitators, and professionals held similar expectations, where their expressed need for support corresponded to three constructs: Readiness for implementation, Implementation climate, and Engaging. Our findings indicate the need for strong leadership engagement to focus on how the healthy lifestyle-promoting practice can be anchored among the professionals. Managers at all levels should communicate the vision and goals, enable facilitators and professionals to improve their competencies, build inter-professional teams, and jointly plan the new practice. CONCLUSION: To change to a healthy lifestyle promoting practice professionals request support from their managers, who in turn need support from the middle and top managers. The requested support includes helping to prioritise health promotion and enabling the primary care centres to build competence and take ownership of the implementation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04799860.

This study revealed that primary health care managers and health care professionals had mutual expectations of supporting a change into a healthy lifestyle-promoting practice before implementation.Strong leadership engagement was perceived as essential across all manager levels, including assistance in prioritising health promotion.The support should enable primary health care centres to build competence and have ownership of implementing a healthy lifestyle-promoting practice.

Expectations on implementation of a health promotion practice using individually targeted lifestyle interventions in primary health care: a qualitative study.

BACKGROUND: There is moderate to strong evidence of the effectiveness of health-promotion interventions, but implementation in routine primary health care (PHC) has been slow. In the Act in Time project implementation support is provided for a health promotion practice using individually targeted lifestyle interventions in a PHC setting. Identifying health care professionals' (HCPs') perceptions of barriers and facilitators helps adapt implementation activities and achieve a more successful implementation. This study aimed, at a pre-implementation stage, to describe the expectations of managers, appointed internal facilitators (IFs) and HCPs on implementing a healthy lifestyle-promoting practice in PHC. METHODS: In this qualitative study five focus group discussions with 27 HCPs and 16 individual interviews with managers and appointed IFs were conducted at five PHC centres in central Sweden. The PHC centres are participating in the Act in Time project, evaluating the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice. A deductive qualitative content analysis based on the Consolidated Framework for Implementation Research (CFIR) was followed using inductive analysis. RESULTS: Twelve constructs from four of five CFIR domains were derived: Innovation characteristics, Outer setting, Inner setting, and Characteristics of individuals. These domains are related to the expectations of HCPs to implement a healthy lifestyle-promoting practice, which includes facilitating factors and barriers. The inductive analysis showed that the HCPs perceived a need for a health-promotion approach to PHC. It serves the needs of the patients and the expectations of the HCPs, but lifestyle interventions must be co-produced with the patient. The HCPs expected that changing routine practice into a healthy lifestyle-promoting practice would be challenging, requiring sustainability, improved structures, cooperation in inter-professional teams, and a common purpose. A collective understanding of the purpose of changing practice was vital to successful implementation. CONCLUSIONS: The HCPs valued implementing a healthy lifestyle-promoting practice in a PHC setting. However, changing routine methods was challenging, implying that the implementation strategy should address obstacles and facilitating factors identified by the HCPs. TRIAL REGISTRATION: This study is part of the Act in Time project, registered in ClinicalTrials.gov with the number NCT04799860 . Registered 03 March 2021.

Validity and reliability of physical activity measures in multiple sclerosis.

PURPOSE: The purpose was to evaluate the psychometric properties of physical activity measures in persons with multiple sclerosis (PwMS). METHODS: Adults with multiple sclerosis were recruited, n = 30 (validation) and n = 57 (test-retest). Steps measured with PiezoRX, Yamax SW200 and ActiGraph GT9X Link (AGlink) and time in different positions measured with AGlink were validated against data from video analysis. Psychometric properties of the Physical Activity and Disability Survey - Revised Swedish version (PADS-R(Sw)) was evaluated. RESULTS: The most valid measures were AGlink using the low-frequency extension filter, and PiezoRX with median absolute percentage errors (MeAPEs) of 0.9-3.1% and 1.3-3.3%. The MeAPEs were higher for Yamax SW200 (2.9-21.0%), AGlink display (3.6-44.8%) and AGlink normal filter (8.9-48.9%), indicating low validity. AGlink was not valid in measurements of sitting (MeAPE 12.0-12.5%) or lying (MeAPE 31.0-41.7%). The correlation between PADS-R(Sw) and AGlink steps was r = 0.492 (p = .009). The relative reliability of PADS-R(Sw) was ICC2,1 0.85 (CI 0.76-0.91), and absolute reliability was SEM 0.54. CONCLUSION: AGlink and PiezoRX were valid measures of steps in PwMS. The questionnaire PADS-R(Sw) was valid, with high relative reliability, but its absolute reliability was unsatisfactory.

Implementation of a Health Promotion Practice Using Individually Targeted Lifestyle Interventions in Primary Health Care: Protocol for the "Act in Time" Mixed Methods Process Evaluation Study.

BACKGROUND: There is growing evidence that noncommunicable diseases (NCDs) can be attributable to unhealthy lifestyle habits. However, there has been little application of this knowledge in primary health care (PHC). OBJECTIVE: This study aims to evaluate the process and outcomes of a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a PHC setting. This practice is based on national guidelines targeting unhealthy lifestyle habits with a potential risk for NCDs. METHODS: A pre-post implementation study design with a control group is used in a PHC setting in central Sweden. The Medical Research Council guidelines for process evaluation of complex interventions will be applied. The implementation process and outcomes will be assessed using a mix of qualitative and quantitative methods. A strategic sample of up to 6 PHC centers will be included as intervention centers, which will receive a 12-month multifaceted implementation strategy. Up to 6 matched PHC centers will serve as controls. Core components in the implementation strategy are external and internal facilitators in line with the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and the Astrakan change leadership model. Data will be collected at baseline, during the implementation phase, and 4-6 months after the implementation strategy. Questionnaires will be sent to roughly 500 patients in every PHC center and 200 health care professionals (HCPs) before and after implementation. In addition, purposeful sampling will be used for interviews and focus group discussions with managers, HCPs, patient representatives, and internal and external facilitators. Use of data from medical records and activity logs will be an additional data source. RESULTS: Recruitment of PHC centers began in March 2021 and ended in Spring 2022. Based on the planned timeline with the 12-month implementation strategy and 4-6-month follow-up, we expect to collect the final data in Summer 2023. CONCLUSIONS: This study will explain implementation process and outcomes using a multifaceted implementation strategy for a healthy lifestyle-promoting practice in a real-world PHC context. The study is expected to provide new knowledge about the role of facilitators and their contribution to implementation outcomes. These findings can guide policy makers, managers, and PHC staff to integrate health promotion and disease prevention in PHC and provide methodological support to facilitators. TRIAL REGISTRATION: ClinicalTrials.gov NCT04799860; https://clinicaltrials.gov/ct2/show/NCT04799860. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37634.

Pulmonary Function and Respiratory Muscle Strength in Patients with Multiple Sclerosis.

BACKGROUND: In patients with multiple sclerosis (MS), there is a decline in muscle strength and physical capacity due to demyelination and axonal loss in the central nervous system. In patients with advanced MS or in a later stage of the disease, also respiratory impairment may occur. The degree of pulmonary dysfunction in the earlier stages of MS has not been thoroughly described. Therefore, the primary aims of this study are to describe pulmonary function and respiratory muscle strength in patients with a moderate disease course and to identify associations between respiratory muscle strength and functional capacity. METHODS: A sample of 48 patients with a diagnosis of MS and mean age 56 ± 11 years was studied using a descriptive cross-sectional design. The patients had a disease duration of 24 ± 11 years and a median Expanded Disability Status Scale (EDSS) score of 4.5 (interquartile range 4.0-6.5). Pulmonary function assessed by spirometry, respiratory muscle strength, peak cough flow and peripheral oxygen saturation, subjective breathing and coughing ability, and physical capacity measured using the 6MWT were evaluated. RESULTS: The patients had normal pulmonary function with no significant abnormalities in dynamic spirometry (vital capacity 103 ± 16% predicted, forced expiratory volume in 1 second 95 ± 15% predicted). Peak expiratory flow rate 89 ± 17% predicted was in the lower limit of normal. Respiratory muscle strength, determined by maximal inspiratory (MIP) and expiratory (MEP) static pressures, was normal but with large differences between individuals. MIP ranged from 26 to 143 cmH2O (98 ± 31% predicted); the MEP values ranged from 43 to 166 cmH2O (104 ± 29% predicted), with two patients having values below the lower limit of normal. Significant positive associations between MIP as well as MEP were found in several pulmonary function variables. A significant negative association was found between EDSS score and MEP (r = -0.312, p = 0.031). Mean peak cough flow was 389 ± 70 L/min, which is comparable with the values reported for healthy adults. The patients did not experience a severely decreased ability to take deep breaths or cough. There was a moderate correlation between MEP and physical capacity, as assessed by the 6MWT (r = 0.399, p = 0.010) and between peak expiratory flow (PEF) and the 6MWT (r = 0.311, p = 0.048). CONCLUSION: Respiratory muscle strength, pulmonary function assessed by spirometry, and peak cough flow were normal in patients with mild to moderate MS; however, there were large individual differences demonstrating low respiratory muscle strength in some patients. Significant associations between MEP and functional capacity and between MEP and disease severity were found, indicating that patients with impaired respiratory muscle strength have lower functional capacity and more severe disease.

Making it work: experience of living with a person who falls due to multiple sclerosis.

Purpose: The purpose of this study was to describe how everyday life is experienced by next of kin sharing residence with a person who falls due to multiple sclerosis (MS).Methods: Twenty face-to-face interviews were analysed using a qualitative content analysis.Results: The overall theme "Making it work" represents the next of kin's struggle to make life work. It comprises three themes: "Taking responsibility", "Making adjustments", and "Standing aside for someone else". The two first themes reflect what relatives do to make the situation work, and the last theme represents what they give up.Conclusion: Next of kin who share residence and everyday life with a person with MS are affected by that person's occasional falls. They often take on the responsibility of preventing such falls and adapt their lives practically and emotionally. However, adaptation is neither always enough or always possible. In these cases, relatives often deprioritize their own needs and free time to make everyday life in the home work.Implications for rehabilitationBy highlighting that next of kin also are affected by the falls of their cohabiting person with multiple sclerosis enhances the importance of fall prevention activities that should include the next of kin.Next of kin to people who occasionally fall due to multiple sclerosis can be in need of both practical and emotional support from the health care system.Enhanced information from the health care system can empower and help them to take care of themselves while managing to live with, care for, and protect the person with multiple sclerosis from falls.

Engagement in performing clinical physiotherapy research: Perspectives from leaders and physiotherapists.

OBJECTIVE: The recent increase in physiotherapy research has led to more physiotherapists being involved in research. Consequently, leaders must make a standpoint on whether the department should engage in research, whereas individual physiotherapists have to decide if they want to play an active role in carrying out a research project. The purpose of this study was to explore perceptions and experiences of both participating physiotherapists and their leaders regarding taking part in clinical physiotherapy research projects. METHODS: A qualitative study using face-to-face interviews was conducted. All (n = 8) leaders were interviewed individually. Physiotherapists (n = 18) were interviewed either individually (n = 5) or in small groups including two to three persons (n = 13). The interviews were analysed using inductive conventional content analysis. RESULTS: There was a consensus that engagement of the leaders was a prerequisite for entering research projects and that the research had to be in line with the department's regular assignment. For the physiotherapists, the key factors for success were having designated time and having support from their leader, especially when feelings of responsibility became overwhelming. The leaders stressed the importance of being well informed. Participating in clinical research created value such as personal and professional growth for the physiotherapists, who also inspired their colleagues and thus positively affected the organization. Engaging in research contributed to being an attractive employer and gave a boost to evidence-based practice. CONCLUSION: The study provides perspectives from leaders and physiotherapists on engaging in research. There was a consensus that participating in a research project was beneficial for the organization, the individual physiotherapist, and the patients. However, clinical applicability, support, sufficient time, and early involvement of leaders are significant prerequisites.

Balance, gait, and falls in multiple sclerosis.

Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) and the most widespread nontraumatic cause of disability in young adults around the world. MS occurs in people of all ages, races, and ethnicities. MS is characterized by clinical symptoms resulting from lesions in the brain, spinal cord, or optic nerves that can affect balance, gait, and fall risk. Lesions accumulate over time and occur in different areas of the CNS causing symptoms that include weakness, spasticity, and fatigue, as well as changes in sensation, coordination, vision, cognition, and bladder function. Thus, it is not surprising that imbalance, gait dysfunction, and falls are common in people with MS. The overwhelming majority have abnormalities of postural control and gait even early in the disease course. In all, 50-80% have balance and gait dysfunction and over 50% fall at least once each year. Balance dysfunction in MS is conceptualized as three interrelated problems: decreased ability to maintain position, limited and slowed movement towards limits of stability, and delayed responses to postural displacements and perturbations. In addition, functional balance performance may be affected by impaired dual-task integration. Walking changes in MS include reduced gait speed, impaired walking balance, and reduced walking-related physical activity. Falls in people with MS are associated with injuries, reduced participation, and increased fear of falling. A wide and growing range of rehabilitation and medical interventions are available to address the changes in balance, gait, and fall risk associated with MS.

Balance exercise facilitates everyday life for people with multiple sclerosis: A qualitative study.

OBJECTIVES: The aim of this qualitative study was to describe the experience and perceived effects on everyday life for people with multiple sclerosis after participating in a balance exercise programme focusing on core stability, dual tasking, and sensory strategies (the CoDuSe programme). METHODS: A qualitative approach was chosen, using face-to-face interviews analysed with content analysis. Twenty-seven people with multiple sclerosis (20 women, 7 men) who had participated in the CoDuSe programme were included. All could walk 20 m with or without walking aids but could not walk further than 200 m. The CoDuSe programme was given twice weekly during a 7-week period. RESULTS: The analysis revealed five categories. Learning to activate the core muscles described how the participants gained knowledge of using their core muscles and transferred this core muscle activation into everyday life activities. Improved bodily confidence covered narratives of being more certain of the ability to control their bodies. Easier and safer activities showed how they could now perform activities in everyday life more safely and easily. Increased independence and participation involved the participants' improved ability and self-confidence to execute activities by themselves, as well as their increased participation in activities in daily living. Experiences of the balance exercise programme revealed that they found the programme novel and challenging. The overall theme was balance exercise facilitates everyday life. CONCLUSION: Participating in the CoDuSe programme was perceived to facilitate everyday life for people with multiple sclerosis. Taking part in the balance exercise programme taught the participants how to activate and use the core muscles, which increased their bodily confidence. Having increased bodily confidence helped them to perform everyday life activities with more ease and safety, which increased their independence and participation. The participants described the CoDuSe programme as novel and challenging, yet feasible.

Falls in people with multiple sclerosis: experiences of 115 fall situations.

OBJECTIVES: The aim was to describe falls and the perceived causes, experienced by people with multiple sclerosis shortly after falling. DESIGN: A qualitative study using content analysis and quantitative data to illustrate where and why people report falls most commonly. Semi-structured telephone interviews were performed. Interviews were conducted shortly (0-10 days) after a fall. SUBJECTS: In all, 67 informants who had reported at least one fall during the previous three-month period and who used a walking aid participated. RESULTS: A total of 57 (85%) informants fell at least once during eight months resulting in 115 falls; 90 (78%) falls happened indoors, most commonly in the kitchen ( n = 20; 17%) or bathroom ( n = 16; 14%). Informants fell during everyday activities and walking aids had been used in more than a third of the reported falls. The falls were influenced of both intrinsic and extrinsic factors. Two categories emerged from the analysis: 'activities when falling' and 'influencing factors'. The category contained three (basic activities of daily living, instrumental activities of daily living and leisure and work) and six (multiple sclerosis-related symptoms, fluctuating body symptoms, being distracted, losing body control, challenging surrounding and involvement of walking aid) subcategories, respectively. CONCLUSION: The majority of falls occurs indoors and in daily activities. Several factors interacted in fall situations and should be monitored and considered to reduce the gap between the person's capacity and the environmental demands that cause fall risk. Fluctuation of bodily symptoms between and within a day is a variable not earlier targeted in multiple sclerosis fall risk research.

Comparison of trunk impairment scale versions 1.0 and 2.0 in people with multiple sclerosis: A validation study.

BACKGROUND: Trunk control impairment often accompanies multiple sclerosis (MS). Trunk stability is necessary for movements of extremities, as are selective trunk movements for normal gait. Measuring trunk function is thus of interest. METHODS: We examined the relationships between the Trunk Impairment Scale (TIS1.0 and TIS2.0) and the Berg Balance Scale (BBS), 5 sit-to-stand test (5STS), Timed Up and Go test (TUG), 10-m timed walk test (10TW), 2-min walk test (2MWT), Falls Efficacy Scale - International, and 12-item MS Walking Scale (MSWS-12) in 47 outpatients. We determined construct validity by calculating the degree to which the TIS versions produced different scores between known groups: use or nonuse of walking aid, MS disability status, and whether participants experienced a fall or not during 14 weeks. RESULTS: TIS correlated moderately with BBS and 5STS; moderately (TIS1.0) or weakly (TIS2.0) with TUG, 10TW, and 2MWT; and weakly to moderately with MSWS-12 in subgroups with Expanded Disability Status Scale (EDSS) >6.0. No other clear correlation patterns were found. TIS did not discriminate between known groups. CONCLUSIONS: TIS1.0 is recommended for individuals with MS (EDSS score 4.0-7.5). Better trunk function correlates with better balance and walking ability. TIS has limited value in fall risk screening.

Examining the validity and sensitivity to change of the 5 and 10 sit-to-stand tests in people with multiple sclerosis.

BACKGROUND AND PURPOSE: Sit-to-stand transfers are frequently performed, and transfers have been associated with fall risk among people with multiple sclerosis (PwMS). There is limited research regarding the validity of sit-to-stand tests (STSs) in PwMS. The purpose of this study was to investigate the concurrent, divergent, and discriminant validity and sensitivity to change of the 5 and 10 STSs. METHODS: A repeated-measurement design was used, with data collected before and directly after a 7-week intervention, as well as prospectively reported near-fall incidents and falls during a 14-week period. One hundred two PwMS with a limited (≤200 m) but retained (≥20 m) walking ability were identified by physiotherapists at outpatient rehabilitation centres in 5 Swedish County Council areas and invited to participate in an intervention study. Of the 52 participants agreeing to participate and fulfilling the inclusion criteria, 47 managed the tests at baseline, and 39 of these returned complete fall diaries. The main outcomes were the Berg Balance Scale (BBS), Timed Up and Go test (TUG), 10-m walk test, 2-min walk test, Fatigue Scale for Motor and Cognitive Function, falls, near-fall incidents, and use of walking aids. RESULTS: Correlations in the total sample were above .60 between the STSs and BBS, TUG, 10-m walk test, and 2-min walk test and above .50 between the STSs and total number of falls. Both tests discriminated between those who did and did not use walking aids for the TUG, but not between fallers and nonfallers. There were no significant correlations between the STSs and number of falls or near-fall incidents. The STSs did not differentiate between participants with changed and unchanged results on the BBS. DISCUSSION: The 5 and 10 STSs are valid in PwMS with an Expanded Disability Status Scale score ≤6.0 but do not identify fallers and have limited ability to detect change. Copyright © 2017 John Wiley & Sons, Ltd.

The Functional Gait Assessment in People with Multiple Sclerosis: Validity and Sensitivity to Change.

BACKGROUND: Assessments of balance and walking are often performed in rehabilitation of people with multiple sclerosis (MS). The Functional Gait Assessment (FGA) is a test of walking balance including challenging items such as walking with a narrow base of support, with eyes closed, and backward. The aim was to investigate the validity (concurrent, discriminant, and known-groups) and sensitivity to change of the modified FGA in ambulatory individuals with MS. METHODS: A convenience sample of 87 individuals with MS was included (mean age, 54 years; 79% women). Concurrent and discriminant validity was investigated using tests of dynamic balance and the Multiple Sclerosis Walking Scale and Multiple Sclerosis Impact Scale (MSIS). Known-groups validity was investigated with self-reported number of falls and use of walking devices. Sensitivity to change was investigated with data from a group balance training study. RESULTS: The median FGA score was 15 (range, 1-26). Concurrent validity with tests of dynamic balance was moderate to strong, with the Timed Up and Go test having the highest correlation coefficient (rho = -0.74). Discriminant validity was shown with a low correlation coefficient with the MSIS psychological subscale (rho = 0.14). The FGA scores differed significantly for users of walking devices versus nonusers but not for reported falls. Sensitivity to change was moderate to low. CONCLUSIONS: The FGA is a valid measure of balance during walking in people with MS, but further investigation is required for the ability to detect people at risk for falls.

CoDuSe group exercise programme improves balance and reduces falls in people with multiple sclerosis: A multi-centre, randomized, controlled pilot study.

BACKGROUND: Imbalance leading to falls is common in people with multiple sclerosis (PwMS). OBJECTIVE: To evaluate the effects of a balance group exercise programme (CoDuSe) on balance and walking in PwMS (Expanded Disability Status Scale, 4.0-7.5). METHODS: A multi-centre, randomized, controlled single-blinded pilot study with random allocation to early or late start of exercise, with the latter group serving as control group for the physical function measures. In total, 14 supervised 60-minute exercise sessions were delivered over 7 weeks. Pretest-posttest analyses were conducted for self-reported near falls and falls in the group starting late. Primary outcome was Berg Balance Scale (BBS). A total of 51 participants were initially enrolled; three were lost to follow-up. RESULTS: Post-intervention, the exercise group showed statistically significant improvement ( p = 0.015) in BBS and borderline significant improvement in MS Walking Scale ( p = 0.051), both with large effect sizes (3.66; -2.89). No other significant differences were found between groups. In the group starting late, numbers of falls and near falls were statistically significantly reduced after exercise compared to before ( p < 0.001; p < 0.004). CONCLUSION: This pilot study suggests that the CoDuSe exercise improved balance and reduced perceived walking limitations, compared to no exercise. The intervention reduced falls and near falls frequency.

The organisation of physiotherapy for people with multiple sclerosis across Europe: a multicentre questionnaire survey.

BACKGROUND: Understanding the organisational set-up of physiotherapy services across different countries is increasingly important as clinicians around the world use evidence to improve their practice. This also has to be taken into consideration when multi-centre international clinical trials are conducted. This survey aimed to systematically describe organisational aspects of physiotherapy services for people with multiple sclerosis (MS) across Europe. METHODS: Representatives from 72 rehabilitation facilities within 23 European countries completed an online web-based questionnaire survey between 2013 and 2014. Countries were categorised according to four European regions (defined by United Nations Statistics). Similarities and differences between regions were examined. RESULTS: Most participating centres specialized in rehabilitation (82 %) and neurology (60 %), with only 38 % specialising in MS. Of these, the Western based Specialist MS centres were predominately based on outpatient services (median MS inpatient ratio 0.14), whilst the Eastern based European services were mostly inpatient in nature (median MS inpatient ratio 0.5). In almost all participating countries, medical doctors - specialists in neurology (60 %) and in rehabilitation (64 %) - were responsible for referral to/prescription of physiotherapy. The most frequent reason for referral to/prescription of physiotherapy was the worsening of symptoms (78 % of centres). Physiotherapists were the most common members of the rehabilitation team; comprising 49 % of the team in Eastern countries compared to approximately 30 % in the rest of Europe. Teamwork was commonly adopted; 86 % of centres based in Western countries utilised the interdisciplinary model, whilst the multidisciplinary model was utilised in Eastern based countries (p = 0.046). CONCLUSION: This survey is the first to provide data about organisational aspects of physiotherapy for people with MS across Europe. Overall, care in key organisational aspects of service provision is broadly similar across regions, although some variations, for example the models of teamwork utilised, are apparent. Organisational framework specifics should be considered anytime a multi-centre study is conducted and results from such studies are applied.

Neurosensory findings among electricians with self-reported remaining symptoms after an electrical injury: A case series.

PURPOSE: Symptoms described in previous studies indicate that electrical injury can cause longstanding injuries to the neurosensory nerves. The aim of the present case series was to objectively assess the profile of neurosensory dysfunction in electricians in relation to high voltage or low voltage electrical injury and the "no-let-go phenomenon". METHODS: Twenty-three Swedish male electricians exposed to electrical injury were studied by using a battery of clinical instruments, including quantitative sensory testing (QST). The clinical test followed a predetermined order of assessments: thermal perceptions thresholds, vibration perception thresholds, tactile gnosis (the Shape and Texture Identification test), manual dexterity (Purdue Pegboard Test), and grip strength. In addition, pain was studied by means of a questionnaire, and a colour chart was used for estimation of white fingers. RESULTS: The main findings in the present case series were reduced thermal perceptions thresholds, where half of the group showed abnormal values for warm thermal perception and/or cold thermal perception. Also, the tactile gnosis and manual dexterity were reduced. High voltage injury was associated with more reduced sensibility compared to those with low voltage. CONCLUSION: Neurosensory injury can be objectively assessed after an electrical injury by using QST with thermal perception thresholds. The findings are consistent with injuries to small nerve fibres. In the clinical setting thermal perception threshold is therefore recommended, in addition to tests of tactile gnosis and manual dexterity (Purdue Pegboard).

Temperature measurements with a temporal scanner: systematic review and meta-analysis.

OBJECTIVES: Systematic review and meta-analysis on the diagnostic accuracy of temporal artery thermometers (TAT). DESIGN: Systematic review and meta-analysis. The index test consisted of temperature measurement with TAT. The reference test consisted of an estimation of core temperature. PARTICIPANTS: Clinical patients as well as healthy participants, with or without fever. INTERVENTIONS: Literature search in PubMed, Embase, Cinahl and Web of Science. Three reviewers selected articles for full-text reading after which a further selection was made. Risk of bias was assessed with QUADAS-2. Pooled difference and limits of agreement (LoA) were estimated with an inverse variance weighted approach. Subgroup and sensitivity analyses were performed. Sensitivity and specificity were estimated using hierarchical models. Quality of evidence was assessed according to the GRADE system. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was measurement accuracy expressed as mean difference ± 95% LoA. A secondary outcome was sensitivity and specificity to detect fever. If tympanic thermometers were assessed in the same population as TAT, these results were recorded as well. RESULTS: 37 articles comprising 5026 participants were selected. Pooled difference was -0.19 °C (95% LoA -1.16 to 0.77 °C), with moderate quality of evidence. Pooled sensitivity was 0.72 (95% CI 0.61 to 0.81) with a specificity of 0.94 (95% CI 0.87 to 0.97). The subgroup analysis revealed a trend towards underestimation of the temperature for febrile patients. There was a large heterogeneity among included studies with wide LoA which reduced the quality of evidence. CONCLUSIONS: TAT is not sufficiently accurate to replace one of the reference methods such as rectal, bladder or more invasive temperature measurement methods. The results are, however, similar to those with tympanic thermometers, both in our meta-analysis and when compared with others. Thus, it seems that TAT could replace tympanic thermometers with the caveat that both methods are inaccurate. TRIAL REGISTRATION NUMBER: CRD42014008832.

A family matter--when a parent is diagnosed with multiple sclerosis. A qualitative study.

AIMS AND OBJECTIVES: The aim was to explore and describe from a triple perspective--that of the ill parent, the healthy parent and the children--experienced issues that are important to acknowledge and act upon to make it easier for a child to cope when a parent is diagnosed with multiple sclerosis. BACKGROUND: A chronic disease affects the whole family and has a substantial impact on the children. Traditionally, the focus is on the patient, and communication with other family members is not generally integrated into health care. Health care professionals need to be aware of a child's needs when a parent is diagnosed with multiple sclerosis. DESIGN: A qualitative design using content analysis with an inductive approach was used. METHODS: Nine focus group interviews were conducted with the ill parents, the healthy parents and the children separately. RESULTS: Participants jointly indicated that family members need to be recognised, both initially and onwards in their everyday lives. Seven categories were defined: Prerequisites within the families, Initial reactions, Trying to adapt and manage, Developing strategies, Everyday life, Thoughts about the future and Support from health care providers. Together they constituted the theme that multiple sclerosis is a family matter. Both ill and healthy parents wished for support from health care professionals in addressing their children's needs. CONCLUSIONS: Health care professionals need to pay attention to children as a parent's illness affects them. Not only the children would benefit, but so would their parents, as their worries for their children would be reduced. RELEVANCE TO CLINICAL PRACTICE: Staff can be advised to pay attention to the parenting role, how the parenting role and parent-child relationship may change as a result of a chronic disease. Parents may need reassurance and benefit from advice about how to talk to their children about their condition and its impact.

Effects on Balance and Walking with the CoDuSe Balance Exercise Program in People with Multiple Sclerosis: A Multicenter Randomized Controlled Trial.

Background. Balance and walking impairments are frequent in people with multiple sclerosis (MS). Objective. The aim was to investigate the effects of a group-based balance exercise program targeting core stability, dual tasking, and sensory strategies (CoDuSe) on balance, postural sway, walking, perceived walking limitations, and balance confidence. Design. A single-blinded randomized multicenter trial. No intervention was given to controls. Participants. People with MS able to walk 100 meters but unable to maintain tandem stance ≥30 seconds. Eighty-seven participants were randomized to intervention or control. Intervention. The 60-minute CoDuSe group program, twice weekly for seven weeks, supervised by physical therapists. Measurements. Primary outcome was dynamic balance (Berg Balance Scale (BBS)). Secondary outcomes were postural sway, walking (Timed-Up and Go test; Functional Gait Assessment (FGA)), MS Walking Scale, and Activities-specific Balance Confidence (ABC) Scale. Assessments were performed before and after (week 8) the intervention. Results. 73 participants fulfilled the study. There were significant differences between the intervention and the control groups in change in the BBS and in the secondary measures: postural sway with eyes open, FGA, MS Walking Scale, and ABC scale in favor of the intervention. Conclusions. The seven-week CoDuSe program improved dynamic balance more than no intervention.