Samarbeidet mellom utdanning og praksis i helseprofesjonsstudiene kan styrkes: Erfaringer fra utprøving av samarbeidsstillinger

In a pilot project aimed at testing the idea of shared positions, five hospital employees and five university employees from four different health educations participated. Each of them held a 20% position devoted to the collaboration. The purpose of this study is to examine the expectations and experiences regarding positions established to promote cooperation. The collection of data took place through focus group interviews before and after the project, with those employed in the positions participating as informants. The analysis of data was inspired by Malterud’s systematic text condensation. The results reveal that leaders and staff from both the field of education and clinical practice ought to be involved in the development of shared positions. The shared positions may help boosting the status of clinical practice within the education by opening up new arenas of cooperation. The introduction of a systematic approach through new pedagogic tools like the SVIP model and primary supervisor model could strengthen the role of supervisors in clinical practice and provide them with more skills in the supervision of students. New pedagogic meeting points and a clearer distribution of responsibilities in the clinical supervision of students will also enable closer cooperation between the fields of education and clinical practice.I et pilotprosjekt med utprøving av samarbeidsstillinger, deltok fem ansatte i sykehus og fem universitetsansatte fra fire helsefaglige profesjonsutdanninger. Hver av dem hadde 20 % stilling øremerket formålet. Hensikten med studien var å utforske forventninger til samarbeidsstillinger og erfaringer med å ha øremerkede stillinger for samarbeid. Innsamling av data ble gjort gjennom fokusgruppeintervjuer før og etter prosjektet, med de som inngikk i stillingene. Dataanalysen var inspirert av Malteruds systematiske tekstkondensering. Resultatene viser at samarbeidsstillinger må forankres i ledelsen og blant kollegaer, både i utdanning og praksisfelt. Samarbeidsstillinger kan bidra til å øke status for praksisdelen av profesjonsutdanningene ved å legge til rette for nye samarbeidsarenaer.  Etablering av systematikk i samarbeidet gjennom bruk av nye pedagogiske tilnærminger som SVIP-modellen og hovedveiledermodellen, kan styrke rollen til praksisveiledere og gi dem økt kompetanse i veiledning av studenter. Nye pedagogiske møtepunkter og tydeligere rollefordeling i praksisveiledning av studenter vil også kunne styrke samarbeidet mellom utdanning og praksisfelt

Identifying factors associated with sedentary time after stroke. Secondary analysis of pooled data from nine primary studies.

<p><b>Background</b>: High levels of sedentary time increases the risk of cardiovascular disease, including recurrent stroke.</p> <p><b>Objective</b>: This study aimed to identify factors associated with high sedentary time in community-dwelling people with stroke.</p> <p><b>Methods</b>: For this data pooling study, authors of published and ongoing trials that collected sedentary time data, using the activPAL monitor, in community-dwelling people with stroke were invited to contribute their raw data. The data was reprocessed, algorithms were created to identify sleep-wake time and determine the percentage of waking hours spent sedentary. We explored demographic and stroke-related factors associated with total sedentary time and time in uninterrupted sedentary bouts using unique, both univariable and multivariable, regression analyses.</p> <p><b>Results</b>: The 274 included participants were from Australia, Canada, and the United Kingdom, and spent, on average, 69% (SD 12.4) of their waking hours sedentary. Of the demographic and stroke-related factors, slower walking speeds were significantly and independently associated with a higher percentage of waking hours spent sedentary (p = 0.001) and uninterrupted sedentary bouts of <i>>30</i> and <i>>60 min</i> (p = 0.001 and p = 0.004, respectively). Regression models explained 11–19% of the variance in total sedentary time and time in prolonged sedentary bouts.</p> <p><b>Conclusion</b>: We found that variability in sedentary time of people with stroke was largely unaccounted for by demographic and stroke-related variables. Behavioral and environmental factors are likely to play an important role in sedentary behavior after stroke. Further work is required to develop and test effective interventions to address sedentary behavior after stroke.</p

Is long-bout sedentary behaviour associated with long-term glucose levels 3 months after acute ischaemic stroke? A prospective observational cohort study

Background and purpose Sedentary behaviour is a risk factor for vascular disease and stroke patients are more sedentary than their age-matched peers. The association with glucose levels, as a potential mediator, is unclear, and we have investigated the association between long-bout sedentary behaviour and long-term glucose levels in stroke survivors. Methods This study uses data from the Norwegian Cognitive Impairment After Stroke study, a multicentre cohort study. The patients were recruited at hospital admission for acute stroke, and the follow-up was done at the outpatient clinic. Sedentary behaviour—being in a sitting or reclining position—was registered 3 months after stroke using position transition data from the body-worn sensor activPAL attached to the unaffected thigh. A MATLAB script was developed to extract activity data from 08:00 to 10:00 for 4 days and to categorise the data into four bout-length categories. The primary outcome was glycated haemoglobin (HbA1c), analysed at 3 months. Regression models were used to analyse the association between HbA1c and sedentary behaviour in the whole population and stratified based on a diagnosis of diabetes mellitus (DM). Age, body mass index and the use of antidiabetic drugs were added as covariates into the models. Results From a total of 815 included patients, 379 patients fulfilled the inclusion criteria for this study. We found no association between time in sedentary behaviour and HbA1c in the whole stroke population. We found time in sedentary behaviour in bouts of ≥90 min to be associated with a higher HbA1c in patients with DM. Conclusion Long-bout sedentary time is associated with a higher HbA1c in patients with DM 3 months after ischaemic stroke. Future research should investigate the benefit of breaking up sedentary time as a secondary preventive measure.publishedVersio

Plasma Inflammatory Biomarkers Are Associated With Poststroke Cognitive Impairment: The Nor-COAST Study

Background: Inflammation is proposed to be involved in the pathogenesis of poststroke cognitive impairment. The aim of this study was to investigate associations between concentrations of systemic inflammatory biomarkers after ischemic stroke and poststroke cognitive impairment. Methods: The Nor-COAST study (Norwegian Cognitive Impairment After Stroke) is a prospective observational multicenter cohort study, including patients hospitalized with acute stroke between 2015 and 2017. Inflammatory biomarkers, including the TCC (terminal C5b-9 complement complex) and 20 cytokines, were analyzed in plasma, collected at baseline, 3-, and 18 months poststroke, using ELISA and a multiplex assay. Global cognitive outcome was assessed with the Montreal Cognitive Assessment (MoCA) scale. We investigated the associations between plasma inflammatory biomarkers at baseline and MoCA score at 3-, 18-, and 36-month follow-ups; the associations between inflammatory biomarkers at 3 months and MoCA score at 18- and 36-month follow-ups; and the association between these biomarkers at 18 months and MoCA score at 36-month follow-up. We used mixed linear regression adjusted for age and sex. Results: We included 455 survivors of ischemic stroke. Higher concentrations of 7 baseline biomarkers were significantly associated with lower MoCA score at 36 months; TCC, IL (interleukin)-6, and MIP (macrophage inflammatory protein)-1α were associated with MoCA at 3, 18, and 36 months (P<0.01). No biomarker at 3 months was significantly associated with MoCA score at either 18 or 36 months, whereas higher concentrations of 3 biomarkers at 18 months were associated with lower MoCA score at 36 months (P<0.01). TCC at baseline and IL-6 and MIP-1α measured both at baseline and 18 months were particularly strongly associated with MoCA (P<0.01). Conclusions: Higher concentrations of plasma inflammatory biomarkers were associated with lower MoCA scores up to 36 months poststroke. This was most pronounced for inflammatory biomarkers measured in the acute phase following stroke.publishedVersio

Recovery after stroke - assessment and treatment; with focus on motor function

The incidence of stroke has not changed significantly in recent decades. However, the actual number of strokes is likely to increase as a consequence of the increasing number of elderly people, creating a significant burden on the health care system, the patients and their families. Pareses are the most common impairment reported after stroke. Motor impairments are associated with reduced self-perceived health, and consequently rehabilitation after stroke has a strong emphasis on physiotherapy and motor training. However, more knowledge about motor recovery and effects of therapy is needed for further improvement of rehabilitation processes and of outcome for the large number of stroke victims. The overall aim of this thesis was to increase the knowledge about motor recovery after stroke by evaluating the effect of two different rehabilitation programmes compared to standard rehabilitation regimes and by investigating changes in brain activity in patients treated in terms of the recommended guidelines in the acute phase and during follow-up. A randomised controlled trial was performed to evaluate the effect of an early supported discharge (ESD) service for patients with acute stroke living in a rural community. Sixty-two eligible patients were included and randomised to either an ESD service or to standard followup. The trial revealed no significant benefit on the Modified Rankin Scale, Barthel Index, Berg Balance Scale or walking speed, but significantly less isolation in the ESD group at the six-week follow-up. However, analysis of all cases with all assessments available showed a non-significant trend toward greater improvement in balance in the ESD group from one week to six weeks follow-up. The trial identified a strong association between initial severe leg paresis, but not with initial moderate leg paresis, and reduced balance one year after the stroke. There was also a strong association between initial inability to walk and reduced balance one year after the stroke. Another randomised controlled trial was performed to evaluate the efficacy and feasibility of Constraint-Induced Movement Therapy (CIMT) organised as group therapy for patients with subacute and chronic stroke. Thirty eligible patients were included and randomised to a CIMT group receiving ten days of intensive motor training of the affected arm or to a control group receiving standard rehabilitation. The CIMT group showed a statistically significant greater improvement in motor function of the affected arm at the post-treatment assessment. However, this difference did not persist at six months' follow-up. There were no differences between the groups at any time in relation to the amount of use of the affected arm or to independence in activities of daily living. Finally, a longitudinal follow-up study was performed to investigate the changes in brain activation patterns from the acute to the chronic phases and their relationship to motor learning after stroke. Twelve eligible patients with acute ischaemic stroke were included and assessed with functional magnetic resonance imaging (fMRI) and clinical tests within one week after stroke and three months later. All patients, except one, had complete recovery of the affected arm according to our criteria. Increased activation in cerebellum, striatum, angular gyrus and insula was revealed in the acute phase compared to the chronic phase. The chronic phase demonstrated a restoration of the lateralised primary motor network, in addition to increased bilateral somatosensory association areas and contralesional secondary somatosensory areas (SII). The activation patterns are not identical but comparable to a motor learning process. In conclusion, this thesis shows that the ESD service did not significantly influence death or dependency, balance or walking speed for patients living in a rural community. However, it may lead to less isolation and a transient improvement in self-perceived health. The thesis also demonstrates that CIMT organised as group therapy is feasible and efficient in the short term but may not be superior to standard rehabilitation in the long term. Finally, the thesis has revealed that the motor network changes associated with successful motor recovery are comparable to changes observed in motor learning studies in healthy subjects, and also indicating the importance of bi- and contralesional brain activation for successful motor recovery after stroke

Arm use in patients with subacute stroke monitored by accelerometry : association with motor impairment and influence on self-dependence

OBJECTIVE: To assess the effect of arm motor impairment on actual arm use in the early post-stroke period and explore its association with self-care dependency. SUBJECTS: Thirty-one patients recruited within the 30 first days after stroke. METHODS: Motor impairment of the upper extremity was measured with Fugl-Meyer Motor Assessment (FMA) and arm use was measured with accelerometry. Arm movement ratio (AMR), the ratio of arm use duration between the more and less affected arm, was calculated. Self-care dependency was defined as needing personal assistance in primary self-care activities. RESULTS: FMA of the more affected arm was strongly associated with AMR (Spearman's correlation coefficient -0.851, p > 0.001), although some patients deviated considerably from the regression line. Covariates did not have any influence on this relation. Both arm motor function and actual arm use related to self-care dependency, but were no longer significant when we controlled for lower extremity motor function. CONCLUSION: FMA and AMR correlated highly in the early post-stroke period. These measures relate to different dimensions of the International Classification of Functioning and Health, and could be supplementary measures to reveal non-use of the affected arm. Arm use and arm impairment were not significantly associated with self-care dependency in our sample

Perceived Caregiver Strain, 3- and 18-Month Poststroke, in a Cohort of Caregivers from the Life after Stroke Trial (LAST)

Aim. To gain more knowledge of caregiver strain in the Life After Stroke Trial (LAST) population. Methods. This is a substudy of the LAST study, including all caregivers’ reports of perceived Caregiver Strain Index (CSI) at inclusion and 18-month follow-up irrespective of group allocation. The checklist “STROBE Statement—Checklist of items that should be included in reports of cohort studies” was used. Caregivers to adults (age ≥18 years), here defined as the person living with, a patient with a first-ever or recurrent stroke, community dwelling, with modified Rankin Scale (mRS) <5 and no serious comorbidities, was invited to fill out the Caregiver Strain Index at three months (10–16 weeks) poststroke. Domains indicating differences of change in perceived strain in the total sample were analyzed in a linear regression analysis. Results. Caregiver strain (n = 147) varying from 5% to 27% was reported by the caregivers at baseline and between 2% to18% at 18-month follow-up. The items indicating the highest level of strain at baseline and 18 months were as follows: “Care giving is confining,” “There have been changes in personal plans,” “There have been emotional adjustments,” and “I feel completely overwhelmed.” The samples were divided into age groups 0–79 years and 80–100 years, indicating a higher strain on the caregiver for persons 80–100 years at 18 months. Conclusion. Caregiver strain was relatively low both at baseline and at 18-month follow-up. Main caregiver strains were reported in terms of a sense of confinement, a tendency of emotional strain, and the altering of plans at both time points. Depression was one of the main explanatory factors for the perceived caregiver strain. The perception of caregiver strain was higher in age groups 80–100 years than age groups 0–79 years

Responsiveness of the Berg Balance Scale in patients early after stroke

The Berg Balance Scale (BBS) has previously shown good measurement properties. However, its ability to detect important change in patients early after stroke is still unknown. The purpose of the present study was to determine the minimal important change (MIC) and its relation to the minimal detectable change (MDC) for BBS in patients early after stroke. This prospective follow-up study included patients within the first 2 weeks after onset of stroke. The BBS, Barthel Index, and Scandinavian Stroke Scale were obtained at inclusion and 1 month later. At the follow-up assessment, the Patient Global Impression of Change was obtained. A receiver operating characteristic (ROC) curve was used to calculate the cut-off value for the MIC. Fifty-two patients (mean age of 78.7, SD 8.5 years) were included. All measures showed a significant improvement from baseline to follow-up. The ROC analysis identified a MIC of ≥6 BBS points, while the MDC was 5.97 BBS points at the 80% confidence level. This study shows that a change of 6 BBS point or more can be considered an important change for patients in the sub-acute phase after stroke, which also represents an 80% probability of exceeding the measurement error. A total of 80% of unchanged patients would display random fluctuations within the bounds of MDC80, while 20% of unchanged patients would exceed MDC80