“Finding stability”. Experienced and measured function in patients undergoing surgery for patellar instability

Bakgrunn: Vurdering av knefunksjon er helt sentralt for diagnostikk, behandling og oppfølging av pasienter med ulike kneledds lidelser. Derfor er det behov for gyldige og pålitelige måleverktøy, inkludert pasientrapporterte utfallsmål og funksjonelle tester, for å kunne evaluere behandling og videre veilede pasienter og klinikere i beslutningstagning rundt retur til idrett. I dag mangler det etablerte retningslinjer for hvordan man best vurderer knefunksjon hos pasienter med patellainstabilitet. Derfor er det viktig å utforske hvordan pasientene selv opplever å leve med et ustabilt kneskjell og hvilke funksjonsproblemer de faktisk har. Formål: Å skaffe ny kunnskap om funksjonelle tester som brukes i avgjørelser om pasientene er klar for å returnere til idrett, i tillegg til å oversette og videre undersøke måleegenskapene til Norsk versjon av spørreskjemaet Banff Patellofemoral Instabilitets Instrument 2.0 (BPII 2.0). Videre har vi ønsket å utforske hvordan pasientene selv opplevde å leve med patellainstabilitet både før og etter kirurgi. Metoder: BPII 2.0 ble oversatt til Norsk (BPII 2.0-NO) før måleegenskapene ble undersøkt. Pasienter operert med patella stabiliserende kirurgi fylte ut BPII 2.0-NO, relaterte spørreskjema og gjennomførte funksjonelle tester før inngrepet og/eller seks måneder post operativt. Førsteinntrykk og innholds validitet, intern konsistens, test-retest reliabilitet, målefeil og konstrukt validitet ble undersøkt i studie I. For å undersøke gjennomførbarhet og egnethet av et sett med funksjonelle tester, fylte 78 pasienter fra en overlappende kohort (studie I og II) ut spørreskjema (BPII 2.0, NPI og et prosjektspesifikt aktivitetsskår) før de gjennomførte funksjonelle tester (YBT-LQ, hinketester og isokinetisk styrketest). Pasientene ble klarert for å returner til idrett hvis de passerte følgende kriterier: ≤4 cm sideforskjell i anterior retning og LSI ≥95% i sum skår på YBT-LQ, gjennomsnittlig LSI ≥85% på alle hinketestene og LSI ≥90% i isokinetisk muskelstyrke. For å utforske pasientenes opplevelser med å leve med patellar instabilitet deltok 15 pasienter i en kvalitativ studie. Intervjuene foregikk seks til 12 måneder etter kirurgi og data ble analysert med systematisk tekst kondensering. Resultater: Studie I: BPII 2.0 gav et tilfredsstillende første-inntrykk, hadde god innholds validitet og ingen gulv- eller takeffekt ble funnet. Videre hadde skjemaet svært høy intern konsistens (α 0.95) og test-retest reliabilitet ICC2.1 0.87 (95% KI 0.77-0.93). Målefeilen var lav (SEM 7.1) med en SDCind på 19.7 poeng og SDCgruppe på 2.8. Åtte av ni hypoteser som utgjorde grunnlaget for å bedømme konstrukt validitet ble bekreftet. Studie II: Sekstito pasienter (82%) gjennomførte alle de funksjonelle testene, mens bare elleve (14%) pasienter ble klarert for retur til idrett. Pasienter med bilaterale problemer hadde høyere LSI-skår sammenlignet med de med unilaterale plager, i tillegg presterte de dårligere på det kontralaterale benet. Omfanget av kirurgi (kun MPFL-R versus kombinert kirurgi) predikerte ikke selvrapportert- eller målt funksjon seks måneder etter kirurgi. Videre var det kun normalisert distanse i anterior retning i det involverte (68.5 ± 5,5 vs. 64.2 ± 7.5; P = 0,04) og det kontralaterale beinet (71.5 ± 4.0 vs. 68,0 ± 7.0; P = 0.01) som var påvirket av omfanget av kirurgi. Studie III: Deltakerne ga grundige og detaljerte beskrivelser av sine erfaringer med å leve med patellainstabilitet. Et sentralt funn var den omfattende innvirkningen instabiliteten hadde på deltakernes liv. De beskrev både mental og fysisk påvirkning. Historiene deres viste en konstant frykt for at patella skulle luksere. For flertallet var denne frykten til stede i årevis før operasjon, og noe av denne frykten opphørte ikke etter operasjon. De fire hovedtemaene fra analysene var: frykt for patella dislokasjoner påvirker daglige aktiviteter, 2) tilpasning til unngåelsesatferd, 3) å være annerledes, misforstått og stigmatisert påvirker selvfølelsen og 4) føler seg sterkere, men stoler likevel ikke helt på kneet etter operasjonen. Konklusjoner: BPII 2.0-NO viste gode måleegenskaper. Kombinasjonen av funksjonstester i studie II var gjennomførbar seks måneder etter patella stabiliserende kirurgi, men veldig få klarte testene noe som tyder på at seks måneder er for tidlig for retur til idrett testing. Foreslåtte kriterier og bruk av LSI ser ut til å være uegnet for pasientgruppen. Patellainstabilitet hadde en omfattende innvirkning på deltakernes hverdagsliv, inkludert evnen til å delta i sosiale- og fysiske aktiviteter både før og etter operasjon. Implikasjoner: Det trengs videre undersøkelser av hvilke tester og kriterier klinikere skal bruke for å vurdere om pasientene har tilfredsstillende knefunksjon for å returnere til idrett. Retur til idrett testing seks måneder etter operasjonen er for tidlig for de fleste pasienter. I tillegg bør behandlingen av disse pasientene inneholde økt oppmerksomhet mot uønskede psykologiske effekter som unngåelsesadferd.Background: Assessment of knee function after patellar stabilizing surgery is a central part of rehabilitation. Therefore, there is a need for valid and reliable tools, including both patient reported outcome measures (PROMs) and functional tests to evaluate treatment and to guide clinicians in for example return to sport decisions. Since conventional return to sport (RTS) assessment currently is lacking for patients with PI, it is important to explore how the patients experience living with this disorder and what functional problems they encounter. Purpose: To gain new knowledge about functional tests used to assess readiness for RTS and activities after surgery for PI. To examine the psychometric properties of the Norwegian version of the Banff Patellofemoral Instability Instrument 2.0 (BPII 2.0) and to deepen insights on how the patients themselves experience to live with PI before and after surgery. Methods: The BPII 2.0 was translated into Norwegian (BPII 2.0-NO) before the measurement properties were examined. Patients surgically treated for recurrent PI completed BPII 2.0-NO, related questionnaires and functional tests before and/or six months postoperatively. A sub-group of 50 patients completed the BPII 2.0-NO twice with a two-week interval. We evaluated content validity, internal consistency, test–retest reliability, measurement error and construct validity. To examine feasibility and appropriateness of the functional assessment, 78 patients from an overlapping cohort (Study I and II) completed PROMs (the BPII 2.0, the NPI and the project-specific activity questionnaire) before they underwent functional testing (Y-balance test-lower quarter (YBT-LQ), single-legged hop tests and isokinetic strength tests). RTS clearance criteria were defined as: ≤4 cm YBT-LQ test anterior reach difference between legs, leg symmetry index (LSI) ≥95% in the YBT-LQ composite score, mean sum score LSI ≥85% of all single-leg hop tests and LSI ≥90% in isokinetic quadriceps strength. To explore the experience of living with PI, 15 patients from the same cohort participated in a qualitative study, using semi-structured interviews six to 12 months after surgery. The data were analysed by systematic text condensation. Results: Study I: BPII 2.0-NO demonstrated good face and content validity. No floor or ceiling effects were found, and internal consistency was excellent (α 0.95). Test-retest reliability was high ICC2.1 0.87 (95% CI 0.77-0.93) and measurement error low (SEM 7.1) with an SDCind of 19.7 points and SDCgroup of 2.8. Eight of nine hypothesis about construct validity were confirmed. Study II: Sixty-four patients (82%) were able to complete all functional tests, while only eleven (14%) patients were deemed ready for RTS, passing all return-to-sport clearance criteria. Patients with bilateral problems had higher LSI scores compared to individuals with unilateral instability and demonstrated worse performance in the contralateral leg. The extent of surgery (MPFL-R only versus combined surgery) did not predict self-reported function or functional performance at the follow-up. Further, only normalized anterior reach distance in involved (68.5 ± 5.5 vs 64.2 ± 7.5; P=.04) and contralateral leg (71.5 ± 4.0 vs 68.0 ± 7.0; P=.01) were affected by the extent of surgery, with a minor correlation (-.234, P=.04 and -.208, P=.06). Study III: Participants offered rich and detailed descriptions of the impact and lived experience of PI. A key finding was that PI had a large impact on participants’ lives. It was described to affect their mental as well as physical well-being. Their stories display a constant fear of dislocating the patella and for the majority, this was present for years before treatment was commenced and some fear still remained after surgery. The four major themes that emerged from the data were; fear of patella dislocations governs everyday life activities, 2) adaptation to avoidance behaviour, 3) feeling different, misunderstood, and stigmatized affects self-esteem and 4) feeling stronger, but still not fully confident in the knee after surgery. Conclusion: The BPII 2.0-NO demonstrated good measurement properties. The current combination of functional tests seems feasible to conduct at six months after patellar stabilizing surgery. However, for patients with PI suggested clearance standards and the use of leg-symmetry-index seems inappropriate. PI had a far-reaching impact in participants` everyday life, affecting ability to participate in social life and physical activities both before and after surgery. Implications: Appropriate tests and the level of performance that suggests readiness for RTS after surgery for PI needs further exploration. RTS testing at six months postoperative seems premature, and patients should be informed that they probably cannot expect to return to sports at this timepoint. The overall treatment of patients with PI should incorporate increased attentions towards unwanted psychological issues such as adaptive behaviour and raised awareness of the knee both before and after surgery.Doktorgradsavhandlin

Geodesics in Heat

We introduce the heat method for computing the shortest geodesic distance to a specified subset (e.g., point or curve) of a given domain. The heat method is robust, efficient, and simple to implement since it is based on solving a pair of standard linear elliptic problems. The method represents a significant breakthrough in the practical computation of distance on a wide variety of geometric domains, since the resulting linear systems can be prefactored once and subsequently solved in near-linear time. In practice, distance can be updated via the heat method an order of magnitude faster than with state-of-the-art methods while maintaining a comparable level of accuracy. We provide numerical evidence that the method converges to the exact geodesic distance in the limit of refinement; we also explore smoothed approximations of distance suitable for applications where more regularity is required

The Importance of Perceived Discrimination and Pre-Adoption Risk for Mental Health Problems among Young Adult Internationally Adopted Students in Norway

The research on mental health problems in adult international adoptees is limited, and while perceived discrimination has been related to increased psychological distress, less is known about its influence on more severe mental health problems. The study investigated mental health problems and the importance of pre- and post-adoption risk factors among internationally adopted students in young adulthood. Data stem from the cross-sectional SHoT study (Students’ Health and Wellbeing Study) of students in higher education in Norway where 409 (0.8%) students identified themselves as internationally adopted. The internationally adopted students reported higher levels of psychological distress and higher occurrence of self-harm, thoughts of non-suicidal self-harm (NSSH), suicide attempts and suicidal ideation compared to their non-adopted peers. Perceived discrimination was associated with increased psychological distress, and higher odds of thoughts of self-harm and suicidal ideation. Being adopted from Asia was associated with lower odds of NSSH and suicide attempts compared to other birth continents. Age at adoption was not associated with any of the mental health outcomes. The results indicate an increased risk of mental health problems for internationally adopted students and suggests that pre- and post- adoption risk factors are associated with different mental health problems.publishedVersio

Study progress, recreational activities, and loneliness in young adult carers: a national student survey

Background: Young adults (18–25 years) with informal care responsibilities have received limited attention in the research literature, and little is known on how caring responsibilities are related to functioning across different life domains. In the present study we examine associations between care responsibilities and study progress, recreational life, and loneliness in young adults in higher education. Methods: A national survey was conducted among Norwegian students in higher education (the SHoT2018-study). The response rate was 30.8%. The current sample is a subsample of the respondents, including young adults 18 to 25 years old, comprising 40.205 participants (70.2% women, mean age 22.0 years, SD = 1.7). Participants reported whether they had regular care responsibility for someone with physical or mental illness, disabilities, or substance misuse. They also answered questions on study progress, number of hours studying, physical exercise, involvement in organized volunteer student activities, number of close friends, and feelings of loneliness. Data were analyzed by Chi-square tests and logistic regression analyses, adjusting for age, sex, and chronic illness. Results: Compared to students without care responsibility, young adult carers (n = 2228, 5.5% of study sample) were more likely to report delayed study progress (OR 1.20, p < .001), higher average number of failed exams (e.g., having failed three times or more, OR 1.31, p = .002), more feelings of loneliness (OR 1.26, p < .001), and slightly fewer friends. Those with limited care responsibility (≤ 1 h daily) were more likely to participate in organized volunteer student activities, whereas students with 2 h or more of caring per day were less likely to participate in leisure student activities. Both study progress and feelings of loneliness were related to care responsibility in a response-dose pattern, with worse outcomes for those with 2 h or more of daily caring responsibility. All comparisons were adjusted for age, sex, and chronic illness. Conclusions: Study progress, recreational activities, and loneliness among young adults are associated with informal caring responsibilities. Professionals in the educational system as well as health personnel should be sensitized to the needs of young adult carers and necessary support made available.publishedVersio

Distribution of non-native brook trout (Salvelinus fontinalis ) across Norwegian waterbodies – is it an invasive species?

Non-native brook trout (Salvelinus fontinalis MITCHILL, 1815) was introduced into Norway in 1883. However, it was not until the late 1970s that this acid-tolerant salmonid species was stocked into many acidified lakes that many populations became established. In 2004, all brook trout stocking in Norway ceased. In this study, we surveyed the distribution of brook trout in Norwegian water bodies. A totally of 202 self-sustaining populations were identified, mostly in unregulated lakes (n=101), streams (n=71) and also to some extent in reservoirs (n=25). Only four populations were found in inland rivers, and one population in a river with Atlantic salmon (Salmo salar L.). Localities with brook trout covered a wide range of altitudes and sizes. Analyses of time-series catches in sympatric populations of brown trout (Salmo trutta L.) and brook trout from 12 lakes (1997-2012) revealed a strong decline in brook trout stocks. A similar development in abundance has also emerged from other studies in recent years. Generally, lake-dwelling brook trout is regarded as a low-risk species with respect to invasiveness. However, brook trout/brown trout interactions may be habitat-specific, as brook trout may dominate in small and relatively cold streams.publishedVersio

Does It Matter Who You Provide Care for? Mental Health and Life Satisfaction in Young Adult Carers Associated with Type of Relationship and Illness Category—A National Student Survey

There is limited knowledge on how caring contexts impact young adults providing informal care for persons with chronic conditions. This study examines associations between outcomes in young adult carers (YACs) and type of relationship (e.g., close or distant family member, partner, or someone outside the family) and type of illness in the care-receiver (e.g., mental, physical illness/disability, or substance abuse). A total of 37,731 students (age 18–25, mean 22.3 years, 68% females) in higher education in Norway completed a national survey on care responsibilities, hours of daily caring, relationship and type of illness, mental health problems (Hopkins Symptoms Checklist-25) and life satisfaction (Satisfaction With Life Scale). More mental health problems and lower life satisfaction were found among YACs compared to students without care responsibilities. The poorest outcomes were reported by YACs caring for a partner, followed by YACs caring for a close relative. Hours spent on daily caring was highest when caring for a partner. Poorer outcomes were reported by YACs caring for someone affected by substance abuse, followed by mental health problems and physical illness/disability. At-risk groups among YACs should be acknowledged and offered support. Future studies are needed to investigate the potential mechanism for the associations between care context variables and YAC outcomes.publishedVersio

Trajectories of psychiatric disorders in a cohort of children with cerebral palsy across four years

Background: Risk of psychiatric disorders has been reported for children and adolescents with cerebral palsy (CP) at different ages, however little is known regarding the long-term trajectories of these disorders. Objective: The aim of this study was to assess the trajectories of psychiatric disorders in children with CP, and to explore their association to risk factors. Methods: We assessed a cohort of children with CP at age seven and again at age eleven with a child psychiatric diagnostic instrument, and parents were informants. We assessed type of CP, Gross Motor Function Classification System (GMFCS) levels, and co-occurring medical conditions in a medical examination, through the medical records, and in an interview with the parents at the onset of the study. Results: We found a significant increase in the prevalence of emotional disorders from seven to eleven years of age (p 0.01), whereas the prevalence of behavioral disorders was stable. Half of the cohort met criteria for a psychiatric disorder at both assessment points. Type of CP, spastic bilateral or unilateral, dyskinetic or ataxic, and co-occurring medical conditions were non-significant predictors of psychiatric disorders. Subthreshold psychiatric disorders at age seven were predictive of psychiatric disorders at age eleven. Conclusions: We found a persistently elevated prevalence of psychiatric disorders in children with CP. Prevalence of behavioral disorders was stable, whereas we found a significant four-fold increase in emotional disorders. Sub-threshold psychiatric disorders predicted later psychiatric disorders. Increased focus on early mental health symptoms as well as more knowledge regarding emotional disorders in children with CP seems warranted.publishedVersio

Illness perception in children with cerebral palsy, a longitudinal cohort study

Background The perception of a disorder could be of importance both in problem solving behaviors, and in the emotional approach towards a disorder. Aims In this paper, we wanted to assess changes in illness perception in children with Cerebral Palsy (CP) over a four-year interval, to compare parental and self-ratings, and to assess illness perceptions according to co-occurring medical and psychiatric disorders. Methods Parents in a cohort of children with CP (N = 36), filled in the Illness Perception Questionnaire at age seven and again at age eleven, and self-reports were gathered at age eleven. Stability across time, informant differences and scores according to motor function, intellectual disability and the prevalence of psychiatric disorders were assessed. Results We found stable parental perceptions across a four –year interval. Parents reported significantly higher impact of CP on the child, than that reported by the child itself. In children with a more severe motor disability and/or co-occurring psychiatric disorders, parents reported significantly higher median scores for perceived impact of the CP condition on symptoms, duration of the condition, and impact on leisure activities, compared to those who had less severe motor disability and/or intellectual abilities within the normal range. Conclusions We propose that illness perception should be included in the follow-up of children with CP, as it may provide a mutual understanding between the child/family and professionals involved in follow-up services, with possible impact on treatment adherence and outcome of the condition.publishedVersio

Från bokomslag till digital bokbild: Materialitet, funktion och teknik på tröskeln till den digitala boken

The focus of this study is the digital representation of the book cover. It discusses the impact of technology on materiality and function of digital book covers based on theoretical perspectives from the materiality of the book, paratexts and media history. The digital book is here defined as a work of literature published in digital form and designated book, with a distinction between e-books requiring reading software and app-books as independent software. A digital book cover is defined as a title specific image designated book cover and/or representing a digital book. Types of digital book covers identified are book covers not adapted for digital presentation; with adaption; and for app-books. These are analyzed in case studies of printed and digital editions of three books. The dematerialization of the book cover is found to confer major losses of materiality, and an increased focus on visual aspects of the front cover. There are losses in paratextual elements of interpretive and commercial function, and a gain in navigational elements due to software menus. Digital book covers could be improved by designing for a complete digital identity, taking into account the possibilities and limitations of the technology surrounding the digital book

Time in bed, sleep sufficiency and emotional and behavioral problems in a general population of 10-12 year old children

Objective: To examine the relationship between time in bed, sleep sufficiency and emotional and behavioral problems in a general population of children aged 10-12 years (N=5095). Methods: Emotional and behavioral problems were assessed using The Strength and Difficulties questionnaire, which was completed by children, parents and teachers. Data on time in bed, sleep sufficiency and potential confounders (gender, pubertal development, mother&rsquo;s education and family economy) were parent reported. Results: Controlling for gender, pubertal development and socioeconomic status, childrens emotional and behavioral problems as rated by parents were related to insufficient sleep. Self-reported emotional symptoms and parent-reported conduct problems were associated with both shorter time in bed and insufficient sleep. Teacher-reported hyperactivity was associated with long time in bed. Conclusions: Children with self-reported emotional symptoms or parent-reported conduct problems seem to spend too little time in bed and to obtain insufficient sleep.publishedVersio