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  • 1.
    Bråndal, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Rehabilitation after stroke with focus on early supported discharge and post-stroke fatigue2016Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background Stroke is a major cause of disability worldwide. After treatment in a specialized stroke unit, early supported discharge (ESD) followed by home rehabilitation has shown to be an effective way to improve patient outcome and quality of care for persons with mild to moderate stroke. ESD service is recommended in the national and international guidelines for stroke care, but has only partially been implemented in Sweden. Following stroke, fatigue is a common consequence that often becomes more evident when the patient comes home. Currently, there is insufficient evidence about how to measure, treat and handle post-stroke fatigue. The overall aim of this thesis was to evaluate and implement early supported discharge (ESD) based on stroke patients experience after discharge from the stroke unit and local conditions. The aim was also to evaluate post-stroke fatigue with a potentially valid and reliable scale and finally to prepare for a study to evaluate cardiorespiratory training as a part of ESD service for patients with post-stroke fatigue.

    Methods In paper I, nine strategically chosen patients were interviewed of their experience of falling ill, the hospital stay, discharge, contact with health care after discharge and their request of support. Papers II-III describe and evaluate the development, content, implementation and effects of a locally adopted method for early supported discharge (Umeå Stroke Center ESD) in modern stroke care. Paper II included 153 consecutive patients and paper III, 30 232 patients with first-ever stroke registered in the Riksstroke registry in Sweden. Paper II evaluated number of patients/year, clinical and functional health status, satisfaction in relation to needs, accidental falls/other injuries and resources with the result summarized in a value compass. The implementation process was evaluated retrospectively by means of Consolidated Framework for Implementation (CFIR). Paper III evaluated patient reported outcome measurements (PROMs) at 3 months. The primary outcome in paper III was satisfaction with the rehabilitation after discharge. Secondary outcomes were information about stroke provided, tiredness/fatigue, pain, dysthymia/depression, general health status and dependence in activities of daily living (mobility, toilet hygiene and dressing). Multivariable logistic regression models for each PROM was used to analyze associations between PROMs and ESD/no ESD. In Paper IV, the Fatigue Assessment scale (FAS) was translated into Swedish and evaluated regarding psychometric properties when self-administered by persons with mild to moderate stroke. 72 consecutively patients selected from the stroke unit admission register received a letter including three questionnaires: the FAS, the Short Form Health Survey (SF-36) subscale for vitality and the Geriatric Depression Scale GDS-15. A second letter with FAS was sent within 2 weeks, for re-test evaluation. Paper V is a study protocol for a planned randomized controlled trial (RCT) of 50 consecutive stroke patients will who receive stroke unit care followed by ESD-service at Umeå Stroke Center, University Hospital, Umeå, Sweden. Paper V will investigate if a structured cardiorespiratory interval training program (CITP) added to the ESD-service may result in relieved post-stroke fatigue and increased oxygen uptake.

    Results The interviews in Paper I revealed three main categories with subcategories: “Responsible and implicated”, “Depersonalized object for caring measures” and “The striving for repersonalization and autonomy”. The findings indicate that coming home gave the informants’ important insights and understanding of the stroke, its consequences and was also an important factor for the recovery. Paper II-III showed that it is possible to develop and implement an adapted ESD service for stroke patients based on the patients’ experiences and requests, evidence-based recommendations and local conditions. The ESD service reduced dependence of activity, increased mobility with seemingly no increased risk of accidental falls or other injuries. The patient satisfaction in relation to needs regarding the ESD was high. Paper III showed that patients that received ESD were more satisfied with rehabilitation after discharge, had less need for assistance with ADL and less dysthymia/depression compared to patients that did not receive ESD. Study IV showed that the Swedish FAS used at home as a selfadministered questionnaire is a reliable and valid questionnaire for measuring fatigue in persons with mild to moderate stroke. The internal consistency was good, the agreement between the test and retest reliability for individual items (weighted kappa) was for the majority of items good or moderate. The relative reliability for total scores was good and the absolute reliability was 9 points. The Swedish FAS had no floor nor ceiling effects and correlated both with the SF-36, subscale for vitality and the GDS-15 indicating convergent construct validity, but not divergent construct validity.

    Conclusion It is possible to develop and implement ESD care for stroke patients based on patients’ experience and needs, evidence-based principles and local conditions. Early supported discharge (ESD) in the setting of modern stroke unit care appears to have positive effects on rehabilitation in the subacute phase. The Swedish FAS used at home as a self-administered questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.

  • 2.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine. Department of Clinical Sciences, Karolinska Institute, Danderyd hospital, Stockholm, Sweden.
    Effect of early supported discharge after stroke on patient reported outcome based on the Swedish Riksstroke registry2019In: BMC Neurology, ISSN 1471-2377, E-ISSN 1471-2377, Vol. 19, article id 40Article in journal (Refereed)
    Abstract [en]

    Background: The efficacy of early supported discharge (ESD) has not been tested in current stroke care setting, which provide relatively short hospital stays, access to hyper-acute therapies and early carotid stenosis interventions. This study aimed to compare patient-reported outcome measures (PROM) among patients with stroke that received modern stroke unit care with or without ESD.

    Methods: Observational study of 30,232 patients with first-ever stroke registered in the Riksstroke registry in Sweden, between 1 January 2010 and 31 December 2013. Patient characteristics were collected from the Riksstroke and Statistics Sweden databases. The primary outcome was satisfaction with the rehabilitation at 3 months after discharge. Secondary outcome were information about stroke provided, tiredness/fatigue, pain, dysthymia/ depression, general health status and dependence in activities of daily living (mobility, toileting and dressing) at 3 months after the stroke. We used separate multivariable logistic regression models for each PROM variable to analyze associations between PROMs and ESD/no ESD.

    Results: The ESD group comprised 1495 participants: the control group comprised 28,737 participants. Multivariable logistic regression models of PROMs showed that, compared to controls, the ESD group was more satisfied with rehabilitation after discharge (OR: 1.78, 95% CI: 1.17–2.49), experienced less dysthymia/depression (OR: 0.68, 95% 0.55–0.84) and showed more independence in mobility (OR: 1.50, 95% CI: 1.17–1.92), toileting (OR: 1.30, 95%CI: 1.05–1.61), and dressing (OR: 1.23, 95%CI: 1.02–1.48).

    Conclusion: In the setting of modern stroke unit care, ESD appeared to have positive effects on stroke rehabilitation, in the subacute phase.

  • 3.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Eriksson, Marie
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Statistics.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lundin-Olsson, Lillemor
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Reliability and validity of the Swedish Fatigue Assessment Scale when self-administrered by persons with mild to moderate stroke2016In: Topics in Stroke Rehabilitation, ISSN 1074-9357, E-ISSN 1945-5119, Vol. 23, no 2, p. 90-97Article in journal (Refereed)
    Abstract [en]

    Objective: To examine internal consistency, test-retest reliability, floor/ceiling effects and construct validity of the Fatigue Assessment Scale (FAS), when self-administrated by persons with mild to moderate stroke.

    Method: The FAS was translated into Swedish and tested for psychometric properties when self-administrated by persons with mild to moderate stroke. Participants, consequently selected from the stroke unit admission register received a letter with three questionnaires: the FAS, Short Form Health Survey (SF-36) subscale for vitality and Geriatric Depression Scale, GDS-15. Within two weeks, a second letter with FAS was sent for re-test.

    Result: Seventy-tree persons with mild to moderate stroke participated in the study. Internal consistency was good (Cronbach’s alpha 0.82). The test and retest reliability of individual items showed that five items out of 10 items were good (weighted kappa > 0.60), four were moderate (0.40-0.60), and one was fair (0.22). The relative reliability between total scores was good (ICC 3.1 = 0.73) and the absolute reliability was nine points, meaning that a change of at least nine points in total score implies a real change of fatigue level. Correlation analysis showed that the Swedish FAS correlated with the SF-36 subscale for vitality (rs = - 0.73) and GDS-15 (rs = 0.62), suggesting convergent construct validity. There were no floor or ceiling effects.

    Conclusion: The Swedish translation of the FAS used as a self-administrated questionnaire is reliable and valid for measuring fatigue in persons with mild to moderate stroke.

  • 4.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Glader, Eva-Lotta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Lundin-Olsson, Lillemor
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Does a cardiorespiratory interval training program at home improve post-stroke fatigue? Study protocol of a randomized controlled trialManuscript (preprint) (Other academic)
  • 5.
    Bråndal, Anna
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Stroke unit at home: A prospective observational implementation study for early supported discharge from the hospital2013In: International Journal of Physical Medicine Rehabilitation, E-ISSN 2329-9096, Vol. 1, no 170Article in journal (Refereed)
    Abstract [en]

    Background: Randomized controlled trials on early supported discharge (ESD) service in stroke have demonstrated favorable results. However, there are difficulties in transferring research results regarding ESD to the clinic. The aim of this study is to describe the method, content, implementation and outcome of ESD in its natural habit for stroke patients.

    Methods: A prospective observational implementation study of 153 consecutive stroke patients with mild to moderate severity with ESD and rehabilitation by a specially trained interdisciplinary team in the patient’s home, directly after discharge from the stroke unit. The interdisciplinary team in the ESD team is similar to the work at the stroke unit. Number of patients/year, clinical and functional health status, patient satisfaction, accidental falls/other injuries and resources were evaluated.

    Results: The number of patients/year in the ESD service has gradually increased from 2005 to 2009.The stroke patients subjected to Umea ESD service in January 2008 until May 2009 had a mean of 8.6 days of in-hospital care. The ESD service included 11 visits and 18 h per patient during 23 days (mean values). Compared with time of enrollment, patients exhibited reduced functional dependency (ADL- stairs 3 (1 - 5) vs. 1 (0–3), median, Q1–Q3, p <0.001, two-sided Wilcoxon Signed Ranks test) and increased mobility (Rivermead Mobility Index, (RMI) 11 (9–13) vs. 13 (12–15), p <0.001) at the time of discharge from the ESD service. Patient satisfaction regarding ESD was high. The long-term risk of accidental falls and other injuries appeared not to be increased.

    Conclusions: It is possible to locally develop and implement ESD care for stroke patients based on evidencebased principles. Our locally adapted ESD care, a stroke unit in the patients’ home, appears to be an appropriate alternative to conventional rehabilitation for patients with mild to moderate stroke.

  • 6.
    Hellström, Thomas
    et al.
    Umeå University, Faculty of Science and Technology, Department of Computing Science. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden.
    Lindahl, Olof
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden.
    Bäcklund, Tomas
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden.
    Karlsson, Marcus
    Umeå University, Faculty of Medicine, Department of Radiation Sciences. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden.
    Hohnloser, Peter
    Umeå University, Faculty of Science and Technology, Department of Computing Science. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden.
    Bråndal, Anna
    Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. University Hospital of Northern Sweden, Umeå, Sweden.
    Hu, Xiaolei
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation. University Hospital of Northern Sweden, Umeå, Sweden; Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Sweden.
    Wester, Per
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. University Hospital of Northern Sweden, Umeå, Sweden.
    An intelligent rollator for mobility impaired persons, especially stroke patients2016In: Journal of Medical Engineering & Technology, ISSN 0309-1902, E-ISSN 1464-522X, Vol. 40, no 5, p. 270-279Article in journal (Refereed)
    Abstract [en]

    An intelligent rollator (IRO) was developed that aims at obstacle detection and guidance to avoid collisions and accidental falls. The IRO is a retrofit four-wheeled rollator with an embedded computer, two solenoid brakes, rotation sensors on the wheels and IR-distance sensors. The value reported by each distance sensor was compared in the computer to a nominal distance. Deviations indicated a present obstacle and caused activation of one of the brakes in order to influence the direction of motion to avoid the obstacle. The IRO was tested by seven healthy subjects with simulated restricted and blurred sight and five stroke subjects on a standardised indoor track with obstacles. All tested subjects walked faster with intelligence deactivated. Three out of five stroke patients experienced more detected obstacles with intelligence activated. This suggests enhanced safety during walking with IRO. Further studies are required to explore the full value of the IRO.

  • 7. Olofsson, Anna
    et al.
    Andersson, Sven-Olof
    Carlberg, Bo
    'If only I manage to get home I'll get better' - interviews with stroke patients after emergency stay in hospital on their experience and needs2005In: Clinical Rehabilitation, ISSN 0269-2155, E-ISSN 1477-0873, Vol. 19, no 4, p. 433-440Article in journal (Refereed)
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