Physiotherapeutic perspectives on balance control …1186992/FULLTEXT01.pdfBalance includes...

Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures

ToOlle and Nisse

Örebro Studies in Care Sciences 75

MIALINN ARVIDSSON LINDVALL

Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures

© Mialinn Arvidsson Lindvall, 2018

Title: Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures

Publisher: Örebro University 2018 www.oru.se/publikationer-avhandlingar

Print: Örebro University, Repro 04/2018

ISSN 1652-1153 ISBN 978-91-7529-247-2

Cover: Illustration made by Gry Arvidsson inspired by the art piece "Balance" of Richard Brixel

Abstract Mialinn Arvidsson Lindvall (2018) Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures. Örebro Studies in Care Sciences 75. The overall aim of this thesis was to investigate physiotherapeutic per-spectives on balance after stroke, in terms of exercises, experiences and measurements. Study I was a pilot randomized controlled trial with 46 persons who had had a stroke, 24 of whom were included in the inter-vention group and 22 who were included in the control group. The in-tervention consisted of 8 weeks of body awareness therapy (BAT). There were no significant differences over time between the groups in the out-come measures of balance, walking, self-reported balance confidence and quality of life. Study II had a qualitative design using content analy-sis. Participants in the intervention group from Study I and the four physiotherapists who had been in charge of the BAT were interviewed. One overall theme emerged: “Simple yet challenging”, which was based on six categories. Study III investigated the validity and test-retest relia-bility of the Six-Spot Step test (SSST), an instrument used to assess the ability to take load on each leg. A cross-sectional design with 81 persons who had had stroke was performed. The convergent validity was strong to moderate, and the test-retest reliability was good. In Study IV a mixed method design including both qualitative and quantitative data collec-tion was used. The participants’ experiences of balance and its influence in everyday life were presented in two themes: “Feeling dizzy and unsta-ble is a continuous challenge” and “Feeling trust and confidence despite dizziness and unsteadiness”. Taken together, the different data sets pro-vided complementary and confirmatory information about balance. All participants experienced the balance limitations as a continuous chal-lenge in everyday life, yet they also felt trust and confidence.

In summary, BAT can be a complement in physiotherapeutic stroke rehabilitation and the SSST can be used as a measuring instrument of walking balance in persons with stroke. Living with balance limitations was experienced as a challenge but the participants were still able to manage their everyday life and activities.

Keywords: Stroke, balance, physiotherapy, measures, experiences

Mialinn Arvidsson Lindvall, School of Health Sciences Örebro University, SE-701 82 Örebro, Sweden

Abbreviation BAT Body Awareness Therapy

WHO World Health Organization

WCPT World Confederation for Physical Therapy

ABC scale activities-specific balance confidence scale

BBS Berg balance scale

DGI dynamic gait index

FSST four square step test

NIHSS national institutes of health stroke scale

SSST six- spot step test

SF-36 short form 36

TST modified timed stands test

TUG timed up and go test

TUG cognitive timed up and go test cognitive

ICC intraclass correlation coefficient

SD standard deviation

SE standard error

SRD smallest real difference

SRD% a percentage value of the smallest real difference

SEM standard error of the measurement

SEM% a percentage value of the standard error of the

measurement

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures

9

Table of Contents

LIST OF PUBLICATIONS ....................................................................... 11

BACKGROUND ...................................................................................... 12 Stroke ....................................................................................................... 12 Balance ..................................................................................................... 13 Physiotherapy and rehabilitation .............................................................. 14

Definitions ........................................................................................... 14 Rehabilitation after stroke ................................................................... 14 Physiotherapy after stroke .................................................................... 15

Body Awareness Therapy ......................................................................... 15 Balance measurements .............................................................................. 16 Experience of balance after stroke ............................................................ 17

RATIONALE ........................................................................................... 18

AIMS ........................................................................................................ 19

MATERIALS AND METHODS .............................................................. 20 Study design ............................................................................................. 20 Sampling and participants ........................................................................ 20

Body Awareness Therapy intervention in Study I ................................. 23 Measurements, Studies I, III and IV ..................................................... 24 Body function ...................................................................................... 24 Dynamic balance.................................................................................. 24 Walking balance................................................................................... 25 Walking endurance .............................................................................. 26 Balance confidence ............................................................................... 26 Quality of life ....................................................................................... 27

Data collection ......................................................................................... 27 Data analysis ............................................................................................ 29

ETHICAL CONSIDERATIONS .............................................................. 33

RESULTS ................................................................................................. 35 Study I. Body Awareness Therapy in persons with stroke: a pilot randomized controlled trial .................................................................. 35 Study II. Body Awareness Therapy for patients with stroke: experiences among participating patients and physiotherapists ............................... 35 Study III. Validity and test-retest reliability of the Six-Spot Step Test in persons after stroke .............................................................................. 37 Study IV. “I can still manage” – a mixed method study of balance after stroke ................................................................................................... 41

10 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures

DISCUSSION ........................................................................................... 43 Results summary .................................................................................. 43 Body Awareness Therapy in persons with stroke ................................. 43 Properties of the Six-Spot Step Test in persons with stroke .................. 46 Living with balance limitations after stroke ......................................... 48

Methodological considerations ................................................................. 50 Measurements ...................................................................................... 50 Participants .......................................................................................... 50 Data collection ..................................................................................... 51 Data analysis ........................................................................................ 52

CONCLUSION ........................................................................................ 53

CLINICAL IMPLICATIONS ................................................................... 54

SAMMANFATTNING PÅ SVENSKA ..................................................... 55

ACKNOWLEDGEMENT ........................................................................ 58

REFERENCES ......................................................................................... 61


11

LIST OF PUBLICATIONS This thesis is based in the following papers, which are referred to in the text by their Roman numerals:

I. Lindvall MA, Forsberg A. Body Awareness Therapy in persons with stroke: a pilot randomized controlled trial. Clinical Rehabilitation 2014, 28: 1180–1188.

II. Lindvall MA, Anderzén Carlsson A, Forsberg A. Basic Body

Awareness Therapy for patients with stroke: experiences among participating patients and physiotherapists. Journal of Bodywork & Movement Therapies 2016, 20: 83–89.

III. Lindvall MA, Appelros P, Anderzén Carlsson A, Forsberg A.

Validity and test-retest reliability of the Six-Spot Step Test in persons after stroke. Physiotherapy Theory and Practice. Accepted for publication.

IV. Lindvall MA, Appelros P, Forsberg A, Anderzén Carlsson A. “I

can still manage” – a mixed method study of balance after stroke. Submitted.

Papers I-III have been reprinted with permission from the publishers: SAGE Publications Ltd, Elsevier Ltd, and Taylor & Francis Group.


BACKGROUND

Stroke Stroke is the most common cause of serious, long-term disability among adults (1). The World Health Organization (WHO)’s definition of stroke is: “rapidly developing clinical signs of focal (or) global disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than that of vascular origin” (2). Stroke events are either ischaemic (85%) or haemorrhagic (15%). Symptoms depend largely on the location and size of the stroke (3). Globally the burden of stroke is increasing, with the majority of the burden being in the low and middle-income countries (1). In Sweden there are about 25 000–30 000 new incidents of stroke per year (4, 5). The number of women who suffer from stroke is slightly lower than that of men. In both women and men, however, stroke is a disease mainly for the ageing population. The median age for having a stroke in Sweden is 74 years for men and 78 years for women (5). Although the incidence of stroke has declined, the prevalence of living with stroke has increased because of the ageing population. Stroke is the somatic disease requiring the most treatment days in hospital. The total social cost of stroke in Sweden is estimated to be SEK 18.3 billion annually (5, 6). Having a stroke is often a life-changing event, as many stroke survivors go from being independent to being dependent. Motor impairment with muscular weakness and limited muscular control is seen in about 80% of persons with stroke (7, 8). After a stroke, impaired postural stability and mobility are common due to various deficits such as hemiparesis, affected sensory function, and spasticity (8). Besides causing impaired postural stability, hemiparesis can also lead to asymmetrical posture, restricted walking balance and dependency in activities of daily living (9-11). Many activities of daily living require the ability to perform activities simultaneously, such as performing a secondary task while walking, which can be challenging for persons with stroke (12, 13). With asymmetric stance and impaired balance, there is a high risk of falling (14, 15). After stroke there is an acute phase where the patient sometimes is not medically stable. The duration of the acute phase varies depending on the severity of stroke. During the first week, spontaneous recovery often takes


13

place (16, 17). The recovery after stroke is complex, usually a combination of spontaneous and learning-dependent processes, including restoring the functionality of damaged neural tissue (restitution), reorganization of partly spared neural pathways to relearn lost functions (substitution) and improvement of the disparity between the impaired skills of the patient and the demands of their environment (compensation) (16). Most improvements take place during the first 6 months, but functional improvement may continue even beyond that time (6, 16). Regaining their walking ability and being part of the society are important factors for many stroke survivors (18).

Balance The word “balance” is often used in association with terms such as “stability” and “postural control”. In this thesis, “balance” is used synonymously with “postural control”. According to Shumway-Cook and Woollacott (19), postural control is an interaction between the individual, the task and the environment. Having postural control involves controlling one’s position in space for stability by keeping the centre of mass within the base of support. All activities require postural control and every task has an orientation component and a stability component. However, the stability and orientation requirements will vary depending on the task and the environment (20). To keep the body in position requires a complex interaction of the musculoskeletal, neuromuscular, and cognitive systems (19). In persons with stroke all the systems involved in balance may be negatively affected (19); therefore, balance is often impaired after stroke (8, 9, 16, 17, 20, 21). To be in balance requires the ability to be in equilibrium while standing and while moving. This includes the ability to shift weight from side to side and back and forth and to make flexible movements (19). This may be challenging for persons after stroke, because of muscle weakness, spasticity and impaired sensory function. The base of support may be compromised owing to limited ability to take load on both legs and an asymmetric posture might be seen (9, 14). Walking balance can be described as the ability to control the centre of mass within the base of support so as to remain upright while walking (10).


Balance includes different types: static balance, which aims to maintain a stationary upright position; dynamic balance, which maintains the balance while moving; proactive balance, which prepares the body for a shift of the centre of gravity; and reactive balance, which includes a movement or a muscular response to have, the ability to maintain stability when something unforeseen occurs (19). In physiotherapeutic assessment and treatment all these types need to be recognized and targeted (7).

Physiotherapy and rehabilitation

Definitions According to the World Confederation for Physical Therapy (WCPT), physiotherapy is a service provided by physiotherapists to individuals and populations to develop, maintain and restore maximum movement and functional ability throughout their lifespan. Physiotherapists are concerned with identifying and maximizing quality of life and movement potential within the spheres of promotion, prevention, treatment/intervention, habilitation and rehabilitation (22). Physiotherapy is based on knowledge about the body and its movement needs, which is central to determining strategies for diagnosis and interventions. Rehabilitation is described by the WHO as a process that enables the individual to identify problems and reach his or her optimal ability, with the aim to facilitate independence and social integration (23).

Rehabilitation after stroke Rehabilitation after a stroke starts early, with functional exercises and respiratory care. There is strong evidence that rehabilitation after stroke should focus on functional exercises, and be intense (24). Rehabilitation after stroke is life-long and the overall aim is to enable activities of daily living. Stroke rehabilitation should focus on each patient’s needs and be individualized and task-oriented (17, 25-31). Multidisciplinary team care, in which the physiotherapist is one of the members of the team, plays an important role in stroke rehabilitation (32). Recovery can continue for months or years after stroke, well beyond the formal rehabilitation period. It is therefore important to continue training (21, 33).


15

Physiotherapy after stroke In persons with residual disability after stroke, balance impairment is often the reason for enlisting the support of a physiotherapist (22). With the goal being to prevent falls, one focus in physiotherapy is to improve walking and balance ability (29, 34). It is also important to enhance balance confidence to further improve walking capacity to enable participation in everyday life (35, 36). There are several studies that have shown positive impact on balance and walking using environment-specific training (30), as well as strength and fitness training (27, 28, 37) and specific walking training (29). However, there is limited knowledge about what is the most beneficial type of training for stroke patients (38). A physiotherapeutic method focusing on stability limits and postural control is Body Awareness Therapy (BAT). In Sweden, BAT is performed in primary health care but not regularly in persons after stroke.

Body Awareness Therapy Body Awareness Therapy is often led by a physiotherapist and can be conducted individually or in groups. The method is inspired by Tai Chi movements, focusing on postural stability by challenging a person’s stability limits (39, 40). Body Awareness Therapy can be described from two perspectives: the experience of the body (the experience dimension) and the actions and behaviour in movement and activities (the movement dimension) (41). The focus of BAT is on finding a new attitude towards the body, thus strengthening the person’s resources, and integrating them into everyday life. A core movement is stimulation of the central axis through weight transfers from left to right, and rotation around the centre of the body. By including these simple repetitive movements that challenge a person’s stability limits, postural control can be improved (39, 40). Another central element of BAT is to make the person aware of their movements and of their own body, as well as making them reflect on how their body feels when performing the movements. To perform a movement slowly many times gives the person the possibility to experience the body and its limits. Movements can be performed in supine or, sitting position or standing. Balance control, free breathing and coordination are integrated in the movements. Body Awareness Therapy has been used for various conditions in different physiotherapy contexts, e.g. for psychiatric disorders (41, 42), chronic pain (43) and schizophrenia (42), in traumatic


femoral amputees (44), and for eating disorders (45) and irritable bowel syndrome (46). Reported positive effects are improved quality of life (45, 46), self-efficacy, body awareness and attitude towards the body, as well as improved self-esteem (41, 42) and also reduced pain (43). Body Awareness Therapy has not previously been used as a balance exercise, but in a study by Sjodahl et al, the outcome measure was gait and, among other results, the authors report decreased need of walking aids in a group of persons with unilateral transfemoral amputations (44).

Balance measurements In clinical practice and research it is important to evaluate changes, improvements or deteriorations after an intervention. It is vital that the measuring instrument reflects the impairments, activity limitations or restrictions of interest. It is also important that the measure is both reliable and valid, and that it is suitable for the functional level of the patient: neither too easy nor too difficult. To facilitate the usability of a measure it is preferable that the procedure should be quick and easy and possible to perform in different environments. There are advanced laboratory facilities aimed at measuring balance, but in clinical practice, advanced technological devices are often not available. In physiotherapy clinics, balance and walking are often evaluated by different functional tests, such as the Timed Up and Go (TUG) test (47) and different tests of walking such as speed, endurance and dual-task performance tests (48-50). To measure balance an instrument should include different types of balance such as static, dynamic, and pro- and reactive balance (19). Another aspect of balance is subjectively experienced balance performance. Examples of instruments of subjective experience of certain limitations, such as fear of falling or self-rated balance confidence, are the Falls Efficacy Scale and the Activities-specific Balance Confidence Scale (51, 52). Balance confidence is a usable factor in enhancing and predicting balance and walking ability post-stroke (35, 53-55). To measure balance in persons after stroke there are several valid and reliable measurements used in both clinical practice and research, such as the Berg Balance Scale (BBS) (56, 57), the Dynamic Gait Index (DGI) (50,


17

58) and the TUG test (47, 59). However, the asymmetric weight distribution (17) may not be fully captured by these instruments and therefore the question arises whether the measure called Six-Spot Step Test (SSST) (60) could be of use. This test was originally developed as a walking test for persons with multiple sclerosis (MS) (60). It includes a dual-task challenge with a forced weight shift from one foot to another, while walking a short distance. The SSST can be seen as a measure of walking balance including a dual-task. The SSST could provide a comprehensive picture of walking capacity after stroke, but its psychometric properties, validity and reliability in persons with stroke need to be evaluated prior to using it in clinical practice and research.

Experience of balance after stroke To get a more comprehensive picture of balance limitations after stroke it is important to also focus on the individual’s perspective. An important part of balance assessment is to gather self-reported information on participation in social roles and activities. To develop more individualized rehabilitation interventions and to more individually describe a person’s balance, knowledge about both perceived and measured balance is required (35, 61). Qualitative studies in which persons with stroke have had the opportunity to describe their experience of balance control in everyday life are scarce. Having good balance is described as an important factor in outdoor walking and participation in exercises (62, 63). Experience of fears related to falls (64, 65) can vary from limited awareness to pervasive fear (65). Smith et al suggest that discussing strategies and assessing fear of falling could help the persons to manage their fears (64). To have sufficient balance is mandatory for activity and participation but there is a lack of knowledge about how persons who have had a stroke experience their own balance. This could be a barrier to understanding the complexity of impaired balance and to further developing patient-centred interventions.


RATIONALE After a stroke many persons remain chronically disabled, with a need for further rehabilitation. Rehabilitation focusing on balance and walking is a way to increase activities and perceived participation in society. The movements in BAT aim to challenge the limits of stability and strengthen the patient’s own resources. Studies using BAT in different diagnosis groups have shown improved postural control. With its focus on balance, BAT may be beneficial also for persons with hemiparesis after stroke. Body Awareness Therapy is often used and performed by physiotherapists in primary health care. There may be some differences in physiotherapists’ and patients’ descriptions of characteristics of a physiotherapy session. Therefore, to get a deeper and fuller description of a course of BAT it is valuable study to both the effects of the therapy, and patients’ and physiotherapists’ experiences of it. Although there are several valid and reliable measures of balance for persons with stroke, there is a need to also measure unilateral limitations and asymmetric weight distribution during walking. The SSST includes these aspects of balance and can be used in the assessment procedure, but its psychometric proprieties have not been investigated for stroke. There are several studies presenting outcome of balance using test instruments and rating scales; however, few studies report on persons with stroke describing their balance limitations in their own words. By combining all these different perspectives, this thesis will investigate and contribute to a wider understanding and knowledge of balance in persons who have had a stroke.


19

AIMS The overall aim of this thesis was to investigate different aspects of balance control after stroke, in terms of exercises, experiences and measurements. In Study I the aim was to investigate the effects of BAT on balance, mobility, balance confidence, and subjective health status in persons with stroke. In Study II the aim was to describe the experience of an 8-week programme of BAT from the perspective of both persons with stroke, and physiotherapists. In Study III we aimed to investigate the convergent and discriminant validity and test-retest reliability of the SSST in persons with stroke. The aim of Study IV was to describe experiences of living with balance limitations after a first-ever stroke. A further aim was to investigate the concordance between experiences of balance limitations, perceived balance, and measured balance control in order to reach a more comprehensive understanding of balance in this population.


MATERIALS AND METHODS

Study design Four separate data collection procedures were used in this doctoral thesis. Study I was a randomized controlled trial (RCT) with an experimental intervention consisting of 8 weeks of BAT and an untreated control group. Study II was a qualitative descriptive interview study. In Study III a cross-sectional design was used to investigate the validity and test-retest reliability of the SSST. In Study IV a mixed method design including both qualitative and quantitative data collection was used.

Sampling and participants Table 1 presents background variables of the participants in Studies I–IV. In Studies I–III, persons diagnosed with stroke were recruited using convenience sampling through primary health care centres in Region Örebro County. In Studies I and II the inclusion criteria were: >6 months since onset of the most recent stroke, ability to walk a distance of 100 metres with or without assistance, and subjectively experienced balance impairment. Study I was a pilot study to evaluate BAT in persons with stroke and based on this type of study it was considered reasonable to include 20–25 participants in each group. Altogether 69 invitation letters were sent out by mail and after 1 week each person was contacted by phone and provided with verbal information about the study. Forty-six persons agreed to participate, of whom 24 were randomized to the intervention group and 22 to the control group. Randomization to intervention or control was conducted in blocks of four to six persons at each primary health care centre, using sealed envelopes that were opened after the baseline tests. For participants randomized to the control group, no further intervention was carried out, and all participants were instructed to continue with their usual daily activities. There were three dropouts in the intervention group. All persons who completed the intervention in Study I were invited by mail and also by phone to participate in the interviews in Study II and all agreed to be interviewed. The four physiotherapists who were responsible for the BAT intervention were likewise invited to be interviewed and all agreed. They had further training and 15–20 years of clinical experience in


21

in BAT. A total of 21 persons with stroke and four physiotherapists agreed to participate in the study. In Study III the inclusion criteria were: >6 months since onset of the most recent stroke, self-reported walking impairment, and walking ability of at least 10 metres with or without using a walking aid. We aimed to recruit about 80 individuals as recommended for reliability studies (66, 67). The persons with stroke received both written and verbal information about the study. Letters were mailed to them or handed to them by the physiotherapists at the health care center. Each person was thereafter contacted by telephone and provided with verbal information about the study. A total of 81 persons agreed to participate in the study. In Study IV, the inclusion criteria were: having had a first-ever stroke in 2015–2016, living in Örebro County, and having reported impaired balance ability, unaffected speech, independence in toileting and dressing, and walking ability indoors and outdoors with or without a walking aid, in the 3-month follow-up questionnaire of the Swedish Stroke Register (Riksstroke). Study IV had a mixed method design (68) with a qualitative approach and it was aimed to include about 20 persons. A total of 45 persons were consecutively by mail and thereafter by phone to invite them to participate. As well as using a consecutive approach, a purposeful sampling was used based on background variables, such as age and sex, in order to achieve a maximum variation sample. Twenty persons initially agreed to participate; however, one person later declined further participation, thus giving a sample size of 19 participants. Exclusion criteria in all studies were: having medical, physical or cognitive impairment that affected the ability to actively participate or to understand written and verbal instructions. Self-reported impairments other than stroke that significantly affected gait performance were further exclusion criteria.


Table 1 Background variables of the participants in Studies I–IV

*In Study IV, time since most recent stroke is given in months.

Study I Study II Study III Study IV Variables Intervention

group (n=24)

Control group (n=22)

(n=21)

(n=81)

(n=19)

Mean (standard deviation) (range) Age, yrs 62.1 (11.4)

(42–82) 65.6 (9.2) (42–81)

62.1 (10.9) (42–80)

70.3 (7.9) (51–86)

76.7 (11.8) (42–92)

Time since most recent stroke, yrs

4.1 (3.8) (0–15)

4.2 (4.5) (0–15)

4.0 (4.1) (0–15)

4.8 (5.0) (0.5–31)

15 (6.1) (4–22)*

N (%) Male/female 12 (50%)/

12 (50%) 15 (68%)/ 7 (32%)

11 (52%)/ 10 (48%)

47 (58%)/ 34 (42%)

9 (47%)/ 10 (53%)

Hemiparesis, right/left

11 (45.8%)/ 13 (54.2%)

15 (68.2%)/ 7 (31.8%)

11 (52.4%)/ 10 (47.6%)

35 (43.3%)/ 46(56.8%)

10 (52.6%)/ 9 (47.4%)

Type of stroke Intracerebral infarction

16 (66.7%) 18 (81.8%) 13 (61.9%) 60 (74.1%) 16 (84.2%)

Intracerebral haemorrhage

8 (33.3%) 4 (18.2%) 8 (38.1%) 18 (22.2%) 3 (15.8%)

Subarachnoid haemorrhage

0 (0%) 0 (0%) 0 (0%) 3 (3.7%) 0 (0%)

Previous strokes 1 (4.2%) 7 (31.8%) 1 (4.8%) 9 (11.1%) 0 (0%)

One or more falls in the past 3 months

9 (37.5%)

9 (40.9%)

8 (38.1%)

34 (42.0%)

7 (36.8%)

Walking aids None 8 (33.3%) 5 (22.7%) 7 (33.3%) 27 (33.3%) 8 (42.1%) Unilateral support: walking stick/crutch

11 (45.8%) 14 (63.6%) 10 (47.6%) 25 (30.9%) 2 (10.5%)

Bilateral support: rolling walker

5 (20.8%) 3 (13.6%) 4 (19.0%) 23 (28.4%) 9 (47.4%)

Wheelchair outdoors 0 (0%) 0 (0%) 0 (0%) 6 (7.4%) 0 (0%)


23

Body Awareness Therapy intervention in Study I In the RCT the experimental intervention consisted of BAT conducted in groups for 8 weeks, 60 minutes once a week, in a quiet room at each of the four primary health care centres, one group per centre. Participating in four out of eight sessions was set as a minimum for each person taking part in the intervention. The intervention was led by physiotherapists with further training and 15–20 years of clinical experience in body awareness therapy. The choice of movements in the intervention was based on previous studies on BAT and BAT experience of the physiotherapists involved. Prior to the intervention the physiotherapists and researchers decided on a framework including a list of specific movements. The participants were instructed to wear comfortable clothes and no footwear so as to be able to be in contact with the floor during the movements. The sessions started and ended with the participants sitting on chairs. Together with the physiotherapist, the participants reflected on the exercises, experiences, bodily and mental aspects, and their expectations before the upcoming session. The intention was that they should relate how the movements felt in their bodies, and how they had integrated the movements in their everyday life. All group sessions followed the same structure; however, exercises were individually adjusted and the intensity and degree of difficulty were increased by the physiotherapists over the 8-week period. Movements were performed in sitting, standing and supine position. Participants were asked to focus on their breathing and the contact with the chair and the floor. They explored their stability limits by shifting their weight forward, back, and from left to right, until they felt in balance. In standing, the centre line was stimulated through rotation of the body, with the arms softly moving. The participants were encouraged to incorporate the movements in their daily life; however, no specific home exercises were given.


Measurements, Studies I, III and IV

Body function The National Institutes of Health Stroke Scale: Items 5 and 6 was used to assess stroke severity (69). In item 5, with the patient in a supine position, the arm was lifted to 45 degrees; in item 6, also in supine position, the leg was lifted to 30 degrees. Performance was graded from 0 = able to hold the arm for 10 seconds/the leg for 5 seconds, to 4 = no movement in either arm or leg (Study III).

Modified Timed Stands Test: The TST is a measure of overall lower extremity function and has been found to be valid in rheumatoid arthritis and other chronic diseases (70). Time was noted as the participants rose from a chair ten times. Participants were permitted to use the hand rails on the chair (71) (Studies I and III).

Dynamic balance Berg Balance Scale: Score on the BBS was the primary outcome measure in Study I. The BBS measures the ability to assume and maintain a given position while performing a voluntary movement. The scale consists of 14 tasks of varying difficulty that are found in the activities performed in everyday life. One task is to rise from sitting to standing position, another to reach forward, or to pick up something from the floor or stand on one leg. The tasks are graded 0–4. The BSS is a reliable and valid measure for persons with stroke (57, 72) (Study I).

Timed Up and Go test: The TUG test was developed as a measure of functional mobility (47) and has been found to be valid and reliable in persons with stroke (59). In the TUG test the time is recorded when the person rises from a chair, walks 3 metres, turns and walks back and sits down again(47) (Studies I and III).

The Timed Up and Go cognitive: The TUG cognitive test is a measure of functional mobility including a dual-task measure. The TUG cognitive has prognostic validity and can be used to predict falls in elderly people (73). In the TUG cognitive the time taken for the person to perform the TUG test while repeatedly subtracting 3 from a randomly chosen number is recorded (74) (Study I).


25

Four Square Step Test: The FSST is a clinical test of dynamic standing balance. The FSST has good intra- and interrater reliability as well as validity in stroke (75, 76). The FSST tests the ability to quickly step over four sticks of 2.5 cm height placed on the floor at 90 degrees to each other and marking four squares. The person steps forward, backward and sideways, first in a clockwise and then in an anti-clockwise direction, putting most of the load on one leg at a time but making contact with the floor in each square with each foot (77). The time was noted as the participants completed the task without touching a stick. Two trials were performed and the mean value of these was calculated (Study III).

Walking balance Dynamic Gait Index: The DGI assesses dynamic balance in eight items representing different walking tasks. The DGI has been found to be valid and reliable, with good interrater reliability, in persons with stroke (58). The tasks are: changing walking speed, walking while turning the head, walking around or over obstacles, and walking with a pivot turn. Performance in each item is rated by the physiotherapist on a 4-point scale ranging from 0 = severe impairment, to 3 = normal walking ability without a walking aid. The maximum total score is 24 points (50) (Study III). Six-Spot Step Test: The SSST is performed in a taped walkway (test field) that is 5 metres long and 1 metre wide. A circle with a 20 cm diameter is marked in the middle of each end line of the test field. Two more circles of the same size are marked on each of the sidelines of the test field, with a distance from the end line of 1 metre and 3 metres on one side, and 2 metres and 4 metres on the other side. One of the end circles is empty and is used as the starting point. A cylindrical wooden block, with a diameter of 8 cm and a height of 4 cm, and weighing 134 grams, is placed in the centre of the other five circles (60) (see Figure 1). The test person starts in the empty circle at one of the short sides of the test field and the test starts when the participant first lifts one foot from the start circle. The instruction is to do the test in fast walking, criss-crossing from circle to circle and in each trial using the same foot to shove the blocks out of the circles. The test ends when the last block is shoved out of the end circle. The SSST was performed in four trials, and the mean value of these was


calculated; two trials for shoving with the paretic and two for shoving with the non-paretic limb (60). The SSST had not been validated for stroke previously (Studies III and IV).

Figure1. Schematic overview of the Six-Spot Step Test (SSST) test field

Walking endurance Six-minute walk test: The 6-minute walk test is a measure of walking endurance that has been found to be valid and reliable in persons with stroke (48). In the 6-minute walk test in this study, the person walked during 6 minutes and the distance in metres was recorded. A track lap of 30 metres, with every third metre marked, was used (Study I).

Balance confidence Activities-specific Balance Confidence scale: The ABC scale is a patient-reported questionnaire that assesses self-rated balance confidence when performing daily activities (51, 78). The ABC scale has been found to be valid and reliable in persons with stroke (79). A validated Swedish version of the ABC scale was used (79). Using an 11-point scale, the participants reported how safe and secure they felt when performing 16 different indoor and outdoor activities, ranging from 0% = not at all safe and secure, to 100% = completely safe and secure. The item scores were summarized and then divided by 16 (the number of items) (Studies I, III and IV).


27

Quality of life Short Form 36: Subjective mental and physical perceived health status was measured using the Swedish version of the Short Form 36 (SF-36) Health Survey questionnaire (80, 81). The SF-36 contains 36 questions grouped into eight health domain scales. Two aggregated summary scores were calculated, the physical component summary score and the mental component summary score. A higher score indicates better subjective health status (Study I).

Data collection In all the studies the data were collected in a consistent order, starting with background variables such as demographic characteristics, then progressing to use of walking aids, and self-reported number of falls during the last 3 months. Study I: In Study I, data collection took place at four health care centres from October 2011 to December 2012 and was performed by four clinically experienced physiotherapists. The follow-up tests were conducted 1 and 6 weeks after the intervention period (9 and 14 weeks post-baseline, respectively). All measures were performed in a standardized order and if walking aids were used, they were used during all test occasions. The same physiotherapists performed the pre-, post- and the follow-up testing using the BBS, TUG test, TUG cognitive test, 6-minute walk test and TST. The ABC scale and SF-36 were completed by the participants. Study II: In Study II the individual semi-structured interviews (82) with the participants took place at the participants’ respective health care centre about 1 week after the intervention ended, from December 2011 to January 2013. The doctoral student (M.L.A.L.) conducted all the interviews. An interview guide was used, covering experiences of changes in the body, balance and daily living, as well as reflections on the structure and content of the intervention. The interviews lasted between 10 and 40 minutes. For practical reasons, the four physiotherapists were interviewed in pairs. The same interview guide as used for the participants was used for the physiotherapists. The interviews were conducted by the doctoral student (M.L.A.L.) and a second author (A.F.), and lasted approximately


1.5 hours each. All interviews were audio-recorded digitally and transcribed verbatim. Study III: The data collection took place at five primary health care centres in Örebro county in Sweden from June 2014 until November 2015. The tests were performed by five physiotherapists specialized in neurological physiotherapy, including the author, M.L.A.L., performing 70% the data collection. The tests were performed on two occasions, 3–7 days apart. The tests were performed in a standardized order, starting with the ABC scale, followed by the TST, the FSST, the DGI, the TUG test and, finally, the SSST. To keep all conditions as stable as possible, the same physiotherapist performed the tests on both occasions, at the same location in an ordinary hallway at the primary health care centres, and at around the same time of the day. If the person needed a walking aid, it was used during both test occasions. At the first test occasion all balance and walking tests were performed; on the second test occasion only the SSST was performed. The participants were instructed not to change their activity habits between the two test occasions. During the tests they wore comfortable shoes and if necessary they could rest between the measures. Study IV: Data were collected in Örebro County from October 2016 to January 2017. The data collection was conducted at a place chosen by the participants, in the participants’ home (n=16) or at their health care centre (n=3). The data consisted of qualitative interviews and data from measurement of balance using the SSST and the ABC scale. All data were collected on the same occasion, starting with the interview. The semi-structured individual interviews started with a broad initial question, followed by more specific questions based on the study’s aim (68). The participants were asked to describe their experience of balance and balance impairment in their everyday life, including strategies to handle situations that challenged balance control, and how impaired balance affected their life. The doctoral student (M.L.A.L.) conducted the data collection. The interviews took 20–60 minutes, and all interviews were audio-recorded digitally and transcribed verbatim. One pilot interview was performed to test the procedure. The pilot interview was not included in the total sample.


29

Data analysis For the statistical analyses, SPSS version 21.0 and 22.0 (IBM Corp, Armonk, NY, USA) and SAS version 9 (SAS, Cary, NC, USA) were used. To present baseline characteristics and results of the outcome measures, descriptive statistics with mean, standard deviation (SD), minimum and maximum for continuous variables, and number and percentage for categorical variables were used. The confidence interval was 95% and the level of significance was set at 0.05. In Study I intention-to-treat analysis was performed, with data from the last test carried forward. Differences between the intervention and control groups were analysed using independent sample t-test. Paired sample t-test was used to investigate changes within the groups: from baseline at week 0 to follow-up at week 9, and from baseline at week 0 to follow-up at week 12–14. In Study II a qualitative content analysis was performed using an inductive approach. Both manifest and latent content analysis were performed (83). The analysis was conducted using the software program Microsoft Word. The physiotherapists’ and patients’ interviews were analysed separately in the manifest analysis until the preliminary categories were identified. The preliminary categories from the respective data sets were then merged based on common content, and abstracted into six categories and one joint theme covering the content from the perspectives of both the patients and the physiotherapists.


The analysis steps, described in greater detail, were:

Manifest analysis (analysis close to the text):

1. The text was read through and listened to several times by the authors.

2. Meaning units were identified. 3. Each meaning unit was condensed and labelled with a code, while

still preserving the core meaning. 4. The codes were sorted and abstracted into preliminary categories,

illustrating the manifest content of the data. 5. The preliminary categories identified from the analyses of the

physiotherapists’ and patients’ interviews were merged, based on common content, and abstracted into categories.

Latent analysis (interpretation of the underlying meaning):

6. The categories were reflected on, discussed, and either changed or retained. The aim was to identify and formulate an underlying theme combining the different parts into a whole.

In Study III, to evaluate the convergent validity between the first test session of the SSST and the other measures, Spearman’s and Pearson’s correlation coefficients were calculated with correlation coefficients <0.30 interpreted as weak, 0.30–0.59 as moderate, and ≥0.60 as strong (84). Evaluation of validity includes defining the extent to which an instrument measures what it intended to measure (85); convergent validity means that two measures are believed to reflect the same phenomenon while discriminant validity reflects measures that are believed to assess different characteristics (85). Reliability testing by definition includes evaluating reproducibility of values of a test in repeated trials in the same individual(s) (67). To fully assess the reliability of a measurement tool, several statistical methods are needed (86). The intraclass correlation coefficient (ICC) is one (87). The ICC reflects the agreement between two measurements. Here, ICC2.1 was used since this also provided the basis for the calculations of the standard error of the measurement (SEM).


31

The SEM and the smallest real difference (SRD) are other statistical methods used. The SEM is calculated as the square root of the within-subject mean square error from the analysis of variance (67, 88). The SEM% indicates measurement error independent of the units of the measurement. The SEM% represents the limit for the smallest change that indicates a real change for a group of individuals. To define the limit for the smallest change that indicates a real change for a single individual, the SRD (89) was used. Also, the SRD can be divided by the mean of the measurements and multiplied by 100, to give a percentage value (SRD%) (59, 86). Wilcoxon’s signed-rank test was used for analysis of systematic changes between the repeated measures. A Bland-Altman plot was used to visually present the data (90). Bland-Altman plots are useful for determining whether the difference between the measurements is dependent on the mean of the measurements. The possibility of heteroscedasticity can be addressed by performing the Pearson’s correlations coefficient test between the mean and the absolute difference between test 2 and test 1 and the mean values of the two sessions (91, 92). An outlier was considered to be present when the difference between the two tests sessions exceeded 2 SDs. In Study IV the qualitative and the quantitative data were analysed separately (68, 93). The qualitative analysis was performed using the software program NVivo 11 (QSR International, Victoria, Australia), using an inductive qualitative content analysis. The analysis covered both the manifest and the latent content (83). The analysis in Study IV was performed in the same stepwise order as in Study II up to step 4. In Study IV a latent analysis was performed as the next step and in the latent analysis the categories were reflected on in order to identify underlying themes combining the parts into a whole. Two themes were finally identified, reflecting the interpretation of the underlying meaning. For the statistical analyses, SPSS version 22.0 (IBM Corp, Armonk, NY, USA) was used. The results together with the baseline characteristics were presented by descriptive statistics, median, mean, SD and percentages. The mixed analysis was performed in a stepwise procedure (see Figure 2). The qualitative and quantitative data were first separately analysed. In the final step, using the qualitative categories as the starting point, an overall interpretation of any emerging pattern was performed, by adding


quantitative data into a joint display with the categories. The median SSST and ABC outcome for the individuals represented in each category were calculated, to determine whether there were any visible patterns emerging from the data. In this step, by going beyond numbers and allowing the results from the different data sets to complement each other a mixed result emerged.

Figure 2. Overview of the stepwise procedure in Study IV


33

ETHICAL CONSIDERATIONS All four studies (I–IV) have been approved by the Regional Ethical Review Board, Uppsala, Sweden (Studies I–II: 2011/085, Study III: 2014/058, Study IV: 2016/307 and 2016/307-1). Study I was registered in the Clinical Trials Database (NCT01613339). All studies were conducted according to the tenets of the Declaration of Helsinki regarding ethical principles for medical research (94, 95). All participants received both verbal and written information about the respective study, and gave a written consent. In Studies I–III the participants were a convenience sample of persons with stroke visiting the primary health care centre. They were recruited by physiotherapists with experience in neurological stroke rehabilitation. The doctoral student (M.L.A.L) worked part-time at one of the primary health care centres but had no ongoing professional contact with any of the participants. Participants in Study IV were identified from the Swedish Stroke Register (Riksstroke) and were contacted by mail and phone and had no earlier contact with the physiotherapist responsible for the recruitment. It is possible that persons who frequently visited the primary health care centre may have felt obliged to participate in the studies. For this reason, all persons were assured by the physiotherapist responsible for the recruitment that participation was voluntary, that they could leave the study at any time without giving any reason and that participation in the study did not affect other therapy at the primary health care centre (94). One ethical consideration is that performing a balance test might bring the fact of impaired balance back to the person’s mind. Other aspects that could have impact on the persons mind is the interview sessions. Therefore in Studies II and IV the persons had the opportunity to choose the interview location and determine where they would take the balance tests. If the interview session or the balance measure recalled any negative feelings or any concerns related to the study they could contact the author at any time. The author could help arrange for participants to get psychological help if needed. None of the participants in any study reported any negative aspects or asked for further help. Further, since all of the participants had impaired balance there was a risk for accidental falls when performing the balance measures. The balance


measures in the studies were, however, measures usually performed in clinical practice and the physiotherapists responsible for the data collection were used to applying these tests. In order to preserve confidentiality, all data and interview transcripts were provided with a code and no unauthorized persons had access to information about the participants. The data have been confidentially handled and are presented separately for each group. In the qualitative studies we have coded citations and have here cited them verbatim (96).


35

RESULTS

Study I. Body Awareness Therapy in persons with stroke: a pilot randomized controlled trial There were no significant differences in outcome measures over time between the intervention group and the control group. Within the intervention group, significant differences were found between the baseline test and the follow-up test at week 9 for the BBS, where the mean change in the intervention group was 3.6 points and in the control group 0.9; and at week 14, where a mean change of 3.6 points was measured in the intervention group versus 1.3 points in the control group. Significant differences were also found within the intervention group at follow-up week 9 for the TUG cognitive test and the 6-minute walk test, and at week 14 for the TUG cognitive test. Within the control group, significant improvements were found between baseline and the follow-up test at week 14 for the TUG cognitive test and the modified TST.

Study II. Body Awareness Therapy for patients with stroke: experiences among participating patients and physiotherapists An overall theme, “Simple yet challenging”, emerged from the latent content analysis of the six categories, figure 3. The word “simple” describes small movements and simple exercises which everyone was able to participate in, regardless of functional status. “Simple” also illustrates the fact that no special equipment was needed. On the other hand, it was “challenging” for the patients who had physical impairments post-stroke, to face their limitations when performing the balance movements. It was also a challenge to be aware of and contemplate their bodies, and to mentally concentrate and stay focused.


Figure 3 Overview of the theme and categories in Study II

Both patients and physiotherapists described changes after the BAT intervention. Changes such as improved balance were reported by patients and physiotherapists alike. Some patients reported less use of walking aids and several said that after the intervention they were able to walk longer distances, and had better posture. Improved balance in many ways led to increased self-confidence. For example, one patient reported taking the step towards walking in open spaces with no support. The patients expressed that the movements and the way of thinking in BAT were useful in everyday life. Several described using the weight shifting movements to place weight on both sides of the body. Almost all the patients reported that BAT left them with a general positive feeling and with an increased sense of wellbeing and peacefulness in their bodies. The physiotherapists agreed with the patients regarding the patients’ wellbeing and peacefulness. On the other hand, the intervention brought certain challenges. One of these, which was mentioned by both physiotherapists and patients, was related to concentration. Some participants were frustrated at not being aware of or able to feel certain parts of the body because of the effects of stroke; according to the physiotherapists, needing to deal with these frustrations was challenging.


37

Under the category “Integrated knowledge” (Figure 3) both the patients and the physiotherapists expressed that the movements were useful in everyday life, as expressed in the quotations below.

… I think it’s an excellent complement [to regular training] … certain things that I feel are clearly going to be useful to me at home … Not all of the exercises, but … the thing about walking … when I walk, how I should hold myself so that I can … relax and feel, how can I say this, the weight or the balance, if you can call it that … just the bit about … how I should position my body – how straight I am, if I am straight, left and right sides … I try to equalize the pressure on each side, if I can put it that way. Because it’s often been one side that has had to bear most of the load … (Participant 21)

… he found he could concentrate, he could use [the exercises] in his daily life to reduce his spasticity … (Physiotherapist)

Study III. Validity and test-retest reliability of the Six-Spot Step Test in persons after stroke The SSST demonstrated strong convergent validity with the TUG test, DGI and FSST, and moderate convergent validity with the TST and the ABC scale (Table 2). Table 3 presents the mean values from the two test sessions of the SSST. Participants walked significantly faster while shoving the blocks with their non-paretic leg. Thirty-one participants (38%) used one or two canes or crutches to perform all tests. The mean difference between the first and the second test was about 1 second (Figure 4) (Table 3). The Bland-Altman plot gives more values under the line than above, illustrating a better performance in the second test, where 57 (70%) of the participants improved on their performance in test 2 (Figure 4). The plot also shows that the intra-individual SD increased with increased time taken to perform the SSST (Figure 3). Indications of heteroscedasticity, with larger variability for higher test values, were also seen in the plot. Pearson’s correlation coefficient for the absolute difference between test 2 and 1 and the mean of the two sessions was 0.70. One outlier was found (Figure 4), and after it had been removed, heteroscedasticity diminished to a value of 0.60. The test-retest results of the SSST are presented in Table 3. The ICC2.1 values for the SSST ranged from 0.93 to 0.96. The SEM% values ranged between 14.7%


and 20.0%. The SRD% values ranged between 40.8% and 55.4%; the lowest value is based on the mean of the four trials on the SSST (Table 2)

Table 2 Correlations between the Six-Spot Step Test (SSST) and the other tests, using Pearson’s correlation coefficient for timed measures and Spearman’s correlations for rating scales

Test Correlation coefficient

p-value

Timed Up and Go (TUG) test, seconds 0.918 <0.0001

Four Square Step Test (FSST), seconds 0.857 <0.0001

Timed Stands Test (TST), seconds 0.568 <0.0001

Dynamic Gait Index (DGI), points (0–24) -0.832 <0.0001

Activities-specific Balance Confidence (ABC) scale, % -0.596 <0.0001


39

Tab

le 3

Res

ults

of

the

Six-

Spot

Ste

p T

est

(SSS

T)

n=81

per

form

ed o

n tw

o te

st o

ccas

ions

and

sho

win

g sc

ores

for

sho

ving

wit

h th

e pa

reti

c ve

rsus

the

non

-par

etic

limb,

and

the

tes

t-re

test

res

ults

.

Occ

asio

n 1

Occ

asio

n 2

Dif

fere

nce

test

2-1

Var

iabl

e M

ean

tim

e (S

D),

se

cond

s/

Med

ian

(min

/max

)

Wit

hin

grou

p p-

valu

e

Mea

n ti

me

(SD

),

seco

nds/

M

edia

n (m

in/m

ax)

Wit

hin

Gro

up

p-v

alue

SEM

SE

M%

SR

D

SR

D%

95

%

SRD

IC

C2.

1 (

95%

C

I)

Mea

n (S

D)

Lim

its

of

agre

emen

t M

edia

n (m

in; m

ax)

Syst

emat

ic

chan

ges

p-va

lue

Mea

n of

fou

r SS

ST m

easu

res

23.7

(15

.8)/

17

.1

(9.1

; 85.

6)

22.7

(17

.7)/

16

.1

(8.6

;96.

4)

3.42

14

.7%

9.

48

40.8

%

-10.

47

to 8

.49

0.96

(0

.94;

0.

97)

-0.9

9 (4

.77)

(-10

.33;

8.3

6)-1

.55

(-10

.7; 2

1.9)

0.00

11

Mea

n of

tw

o m

easu

res

sh

ovin

g w

ith

the

pare

tic

limb

25.0

(16

.8)/

18

.0

(8.9

; 86.

8)

24.1

(19

.8)/

16

.7

(9.3

; 106

.5)

4.90

20

.0%

13

.59

55.4

%

-14.

53

to

12.6

5

0.93

(0

.89;

0.

95)

-0.9

4 (6

.92)

(-14

.49;

12.

61)

-1.5

6 (-

17.1

3;34

.00)

0.00

17

Mea

n of

tw

o m

easu

res

shov

ing

wit

h th

e no

n-pa

reti

c lim

b

22.4

(15

.6)/

16

.6

(8.7

; 98.

7)

21.4

(16

.1)/

16

.0

(7.8

; 87.

2)

3.94

18

.0%

10

.91

49.8

%

-11.

94

to 9

.88

0.94

(0

.91;

0.

96)

-1.0

3 (5

.50)

(-11

.82;

9.7

6)-1

.19

(-22

.70;

24.

94)

0.00

08

Dif

fere

nce

of s

hovi

ng b

etw

een

the

pare

tic

and

the

non-

pare

tic

limbs

2.6

(7.3

)/

1.4

(-26

.2; 2

4.6)

0.00

01

2.7

(6.9

)/

0.99

(-

21.9

;31.

5)

<0.0

001

CI

= co

nfid

ence

inte

rval

; IC

C2.

1 =

intr

acla

ss c

orre

lati

on c

oeff

icie

nt, S

EM

= s

tand

ard

erro

r of

mea

sure

men

t; S

EM

% =

sta

ndar

d er

ror

of m

easu

rem

ent,

in p

er c

ent

valu

es; S

RD

= s

mal

lest

rea

l dif

fere

nce;

SR

D%

= s

mal

lest

rea

l dif

fere

nce


Dif

fere

nce

test

2-

test

1, i

n se

cond

s

Figure 4 Bland-Altman plot showing the mean time (in seconds) achieved in test 1 and test 2. Dotted lines represent means (bold dotted line) and limits of agreement (light dotted line).

Mean of test 1

and test 2


41

Study IV. “I can still manage” – a mixed method study of balance after stroke All participants experienced the balance limitations as a continuous challenge in everyday life, yet they also felt trust and confidence. Two themes, “Feeling dizzy and unstable is a continuous challenge” and “Feeling trust and confidence despite dizziness and unsteadiness” and seven categories emerged from the latent analysis of the interview data. Both themes illustrate that the impaired balance caused feelings of dizziness and unsteadiness. The first theme, “Feeling dizzy and unstable is a continuous challenge”, contains the participants’ descriptions of balance as a constant feeling of dizziness and unsteadiness. Muscle weakness was expressed as limiting balance in daily life and this caused feelings of anxiety, insecurity and frustration. For many, the balance limitations became more prominent in the dark. The first theme also contains descriptions of the dependence on physical support and the experience that everything took a lot of time.

“…I don’t take long walks nowadays…I feel a little wobbly…because of that ‘balance business.” (Participant 2)

“…get dressed, but it takes so much more time than what it used to take...Things that used to be practically automatic now take time.” (Participant 17)

In the second theme, “Feeling trust and confidence despite dizziness and unsteadiness”, the participants described their capacities and feelings of confidence about still being able to do things themselves in spite of their balance impairment. Balance in everyday life was limited, yet the participants were, to a varying degree, active in social activities. They described having accepted their new life situation and said they were confident in their ability to manage their everyday activities.

“… they help me, they do, but that...I’m stubborn person and I want to manage on my own for as long as I can…”(Participant 11)

“…You can’t say there have been problems; rather...small challenges have arisen, but nothing so significant that I was not able to deal with it.”(Participant 17)


Results for the quantitative measures were: a median time of 20.24 seconds (range 8.9–113.3) for the SSST, and a median score of 67.5 (range 29–98) in the ABC scale. The mixed results illustrating that almost all participants are represented in every qualitative category. There was no explicit association between those scoring low on the ABC test and/or walking slowly in the SSST, and the categories representing experiences of limitations, nor between those scoring higher, walking faster and categories not showing limitations. The different data sets provide different, somewhat complementary and confirmatory information on balance. The mixed results illustrate that impaired balance can be experienced as a challenge and, at the same time, that the individual can feel trust and confidence, no matter how they score on the ABC scale or perform on the SSST.


43

DISCUSSION

Results summary The overall aim of this thesis was to investigate different aspects of balance after stroke, in terms of exercises, experiences and measurements. The first two studies evaluated using BAT in people with stroke. In the RCT no significant differences over time were found between the intervention group after 8 sessions of BAT and the controls. In the qualitative evaluation the participants who had been included in the intervention group described that exercising with BAT resulted in experience of improved balance, as well as a feeling of harmony. Also, they related that it was possible to integrate the BAT movements in their daily life.

The SSST showed strong convergent validity with other instruments of walking and high test-retest reliability. The mixed method results of a low to moderate self-rated balance confidence and slower performance in the walking test did not signify more negative experiences of balance. The qualitative data included participants’ descriptions of experience of dizziness and unsteadiness. Despite continuous challenges with balance, they were able to manage their everyday life and activities.

Body Awareness Therapy in persons with stroke In the quantitative evaluation, there were no significant differences over time in any of the outcome measures between the groups. However, regarding the primary outcome measure in Study I, BBS score, we found a significant improvement over time in the intervention group compared with no improvement in the control group. To the best of our knowledge, only two other studies have applied BAT in persons with stroke. Recently Bang and Cho (97) presented an RCT evaluating the effects of BAT on balance performance in persons with chronic stroke, and Bang et al. presented another RCT on effect of BAT on visual spatial neglect in persons with acute stroke (98). In both studies 15–20 minutes of BAT had been offered as an add-on therapy to walking or task-oriented training (97, 98). Of the two, the sample with chronic stroke were the most comparable to our sample. In that small study twelve persons with chronic stroke were randomized to 20 minutes of BAT and 30 minutes of walking training, five times a week, for 4 weeks. The control group received


walking training for 30 minutes, five times a week, for 4 weeks. Bang and Cho present significant between-group differences on BBS and TUG results (97). There are both differences and similarities between the study by Bang et al(97) and Study I in this thesis. The BAT intervention in both studies was based on the same framework of movements, but the intensity of BAT in Bang et al was much greater and their intervention consisted of both BAT and walking training. By contrast, in our Study I the intervention consisted only of BAT and the controls received no intervention. These studies together suggest that BAT can be used as a complement to physiotherapy but further studies are needed to evaluate the specific effects that BAT may have for patients with stroke, as well as which exercises are the most suitable and at what intensity. In studies including other patient groups, such as fibromyalgia patients (99) and transfemoral amputees (44), the intervention lasted much longer, namely, once a week for 3 months (99) and 10 months (44). Based on these studies it can be deduced that longer and more intensive interventions with BAT are optimal. On the other hand, all these studies have small patient samples and the results should be interpreted with care. There is no gold standard for what constitutes the most beneficial physiotherapeutic training for stroke patients (37). As BAT consists of simple, repetitive movements, with the aim of strengthening the person’s resources and finding a new attitude towards the body, it can be seen as a complement to balance training in persons with stroke. In the qualitative study (Study II), exercising with BAT was described as simple yet challenging. The participants experienced that they had to face their limitations and explore stability limits in different positions, as well as using varying body weight distribution. We were not able to measure body weight distribution. In the study by Sjodahl et al in participants with transfemoral amputation, a more symmetric body weight distribution and less use of walking aids was reported (44). The authors used gait analysis and force plates to examine changes in the legs post-intervention (44). In future research in persons with stroke (a population who often experience difficulties with weight distribution), it would be interesting to use force plates when evaluating BAT. In Study II both the patients and the physiotherapists were interviewed. The results showed that the narratives of the physiotherapists and the


45

participants were mostly similar. Despite some differences pertained to physiotherapists’ and patients’ perspectives of a physiotherapy session where both parties were involved. A physiotherapist’s perspective will probably reflect and be based on theoretical knowledge while patients’ perspectives are built on each individual’s previous life, habits and bodily experiences (100). In Study II, the physiotherapists’ narratives strengthened and confirmed the experiences of the persons with stroke. Both parties described that the movements had an impact on balance performance and also that the movements could be integrated in everyday life. Some also mentioned that they experienced increased self-confidence. Similar findings, with experience of better contact with the body, increased awareness of movement behaviour and changes in posture and balance, were also seen in persons with schizophrenia and their physiotherapists (42, 101). Feelings of harmony and a sense of wellbeing and peacefulness were reported by the patients in our study. The physiotherapists observed reduced tension in the patients, as well as new experiences of connecting with the body. Similar results have also been reported by Hedlund and Gyllensten (101) and Gyllensten et al (102) who studied experiences of BAT in schizophrenia populations. In our study, BAT was described as mentally challenging by both the patients and the physiotherapists. In BAT, a patient has to listen to the body by focusing on both doing and what is experienced by the body. The physiotherapeutic focus in BAT is on resources, and not limitations (102). The patients expressed that it was a challenge to be focused and work through the mind, by thinking of and observing the body and being aware of both sides of the body. The physiotherapist confirmed this description and described the challenge of being the group leader when the participants had difficulty with concentration. A possible explanation for concentration difficulties could be cognitive deficits and difficulties with doing several things at the same time (8). Cognitive status and fatigue were not examined, which can be seen as limiting factors and important variables to consider in future studies. What was highlighted by almost all participants was the value of being part of a group with other persons with stroke. Group activities are often seen as valuable (103) and the participants felt comfortable to share similar experiences and appreciated the opportunity to do so. Although no effects were identified in Study I, the positive experiences narrated by


participants in the qualitative study suggest furthers studies to evaluate BAT in stroke. Previously, positive effects and experiences of BAT have been presented in both qualitative and quantitative studies (42-45). Body Awareness Therapy gives the opportunity to focus on the body while performing weight shifts and rotations. An intervention in which BAT is combined with more stroke-specific movements such as stepping and walking tasks might be a good alternative for increasing balance performance in persons post-stroke.

Properties of the Six-Spot Step Test in persons with stroke Balance deficits can be a continuous challenge for persons post- stroke, as can taking load on the hemiparetic leg (9, 17). This thesis investigated the psychometric properties of a measuring instrument, the SSST, which includes several components that may be challenging for people with hemiparesis after stroke. These components include dual tasks, such as weight shifts or kicking with one leg while walking, and also a cognitive component to plan the performance. Multiple tasks are often performed simultaneously in everyday activities. A measure that has a close relation to everyday life performance can be expressed as ecologically valid (104, 105). To improve balance, challenging dual-task exercises are preferred (106, 107), as plain walking might not be enough of a challenge (19). In Study III in this thesis, the SSST showed strong convergent validity with the TUG test, the DGI and the FSST. Most previous studies of the SSST were performed in people with MS (60, 108-110). In a study by Fritz et al (108), a strong correlation between the SSST and the TUG has been shown. Tests involving longer distances, such as the 2-minute and 6-minute walk tests, have also been used in studies by Fritz et al (108) and Sandroff and colleagues (108, 110). Sandroff et al also showed moderate to strong correlation with balance confidence. They highlighted the novelty of the SSST as a measure of ambulatory function also including elements of balance confidence. In this thesis the SSST also showed moderate correlations with the ABC scale and therefore the SSST could give valuable information about feelings of confidence in ability to carry out activities at home and in the community, as assessed by the ABC scale. The correlation coefficients between the SSST and the FSST and the DGI indicate that the SSST can capture dynamic balance also in persons with stroke.


47

The ICC2.1 values for the SSST in Study III in this thesis ranged from 0.93 to 0.96. In the study by Pavan et al, 75 persons with MS performed the retest after 2 hours with about the same median time in both tests and with an ICC at 0.98 (109). In the study by Nieuwenhuis et al, 41 persons performed the retest after 1–2 hours, with an ICC value of 0.95 (60). A difference between the MS studies and Study III in this thesis was the time between the test and the retest. In Study III the retest was performed after 3–7 days. This time limit was set to avoid a possible learning effect. The participants were instructed not to change their activity habits between the two test occasions and in persons who had their stroke onset more than 6 months previously no differences are to be expected in such a short time. In a study by Callesen et al (111) the retest was taken after 2 days, likewise showing high ICC values. Based on the high SRD% and SEM% values in the present study, the most suitable way of applying the SSST is to calculate a person’s mean time for four trials during which they shove twice with each leg. This is how the SSST was applied in the original study by Nieuwenhuis et al (60) in people with MS. Due to stroke deficits, persons with stroke often have a hemiparetic side (8). Therefore, in Study III the test-retest involved shoving with both the paretic and the non-paretic limb. The reliability values were high for both performances. Participants achieved a faster performance in the SSST when standing on their paretic leg while shoving the block with their non-paretic limb, compared with the opposite. The paretic limb often lacks strength and coordination and in our study population this might have made the test more challenging and slowed down the performance. Another possible explanation for a faster performance when shoving with the non-paretic side could be the possibility to take a quick step with that leg to restore balance after the kick. The variability of within-subject measurements in our study showed limited sensitivity for detecting changes beyond the error threshold due to fairly high SEM% and SRD% values. There are no universally accepted limits for SEM% but Flansbjer et al (59) suggest that values ≤10% are clinically relevant with respect to sensitivity. When introducing a new


measurement it is important that it is valid and reliable in its context, as well as being usable. The SSST was easy and quick to perform in the primary health care settings as in the home environment and the participants enjoyed the “game like” kicking in the test, as has also been reported in a previous study using the SSST (108). Based on the results of this study, the SSST is a valid measure of balance during walking; however, its sensitivity for capturing changes over time needs to be further evaluated.

Living with balance limitations after stroke Having postural control is an interaction of the individual with the task to be done and the environment (19). To investigate these three perspectives of balance control we set up a mixed method study including a measure of balance during walking, assessment of balance confidence, and qualitative interviews. The participants described that despite the continuous balance challenges they were able to manage their lives. Have active coping strategies had previously been found to have a positive impact on quality of life after stroke (112, 113) and subjectively experienced wellbeing was seen to be related to the ability to manage the consequences of stroke (112). The results in the instruments testing balance during walking and balance confidence complemented the narratives in the interviews. Several of our participants expressed that dizziness was a problem. This finding has also been reported in other studies and dizziness can be a barrier to community participation (64, 65). Balance and dizziness were experienced as a challenge when walking outdoors. However, walking outdoors was important to several participants. It was something they did every day, and it was a daily routine they did not want to miss. For others, it was more like training or part of activities such as going to the grocery store or to church. Outermans et al (62) described what keeps people after stroke from walking outdoors. They stated that outdoor walking is linked to the intention to walk, as well as to walking ability and the opportunity to walk (62). All these three factors related to outdoor walking were in a certain way also linked to the experience of balance in Study IV. In the narratives, experience of balance was closely related to the participants’ intention and to their attitudes to balance confidence. It was also related to their ability, in terms of functional impairments, and to the opportunity


49

they had, of carrying out activities such as visiting friends. Walking and balance seem to be close related, as also mentioned by Simpson et al (63). In the present study all participants were able to walk in the community; in future studies it would be interesting to investigate balance experiences in persons with greater walking limitations. Experiences of balance also included feelings of fear of falling. To have something to grab on to, such as walking aids, another person or a wall, was expressed by several of the participants as giving feelings of safety. Feelings of fear of falling in relation to balance and walking are also mentioned by Simpson et al (63). In their study, fear of falling and losing balance was experienced as a barrier to exercise and community participation (63). Fear of falling is common among persons with stroke, and to help these persons to manage their fears related to falls it is suggested to talk about fear of falling (64). In this thesis the participants described fear of falling as a challenge; however, they said that they managed their life even despite this fear. In future research it would be of interest to establish which strategies can make persons with stroke feel in balance in relation to fear of falling. The participants’ narratives and their scoring on the ABC scale were not always consistent. The participants had a median ABC score of 67.5%. In a study by Yiu et al, persons with stroke were reported to maintain lower balance confidence compared with controls for at least 12 months post-stroke (114). A balance confidence score of <80 indicates that there is room for improvement (78). Even though the participants in our study rated perceived balance confidence as low to moderate (67.5), they expressed feelings of acceptance, indicating that they had found solutions in their post-stroke life. These findings are similar to a study by Kubina et al (2013), in which persons with stroke highlighted the importance of being in charge of decisions and contributing in social relationships (115). To get a broader perspective, gain further knowledge and involve these persons in balance rehabilitation, a mix of measured balance, self-rated balance and asking the persons about experience of balance is preferred.


Methodological considerations To meet the overall aim of this thesis, which includes both qualitative and quantitative studies. We have described and investigated balance from different perspectives such as exercise, measuring instruments and experiences.

Measurements The included measurements were chosen for different reasons. The objective as well as the subjective measures covered the different types of balance: dynamic balance (e.g. balance while walking) and static balance. The instruments are often used in stroke rehabilitation. However, measures of cognitive functions and fatigue, if repeated, might have captured more subtle changes when evaluating BAT. A gait analysis with force plates might also have captured changes in balance performance. In Study III a cognitive test and a test screening for falls would have been valuable for testing the usability of SSST as a test in everyday life. In Studies II and IV the data source was qualitative interviews. The credibility was strengthened by the fact that all the qualitative interviews were performed by the doctoral student (M.L.A.L), who is clinically experienced in balance and stroke rehabilitation. To increase dependability and ensure that all interviews concerned the same topics, interview guides were used in both studies (104).

Participants Recruitment of the participants in Studies I–III was by convenience sampling of persons visiting the primary health care centre. Convenience sampling has limitations, such as that persons participating in clinical studies have volunteered to participate and are often positive towards the research and study method and motivated to improve, which may have influenced the results in these studies, and may therefore threaten the external validity. In Study I the participants were informed that they would be allocated to either the control or the intervention group. Some of the participants allocated to the control group expressed disappointment at not receiving the intervention and started exercising on their own. This may explain the improvement seen in some of the measures for the control group and, again, this constitutes a threat to the external validity (104).


51

In Study I it was considered reasonable to include 20 participants in each group because the study had an exploratory approach as BAT had not previously been used in persons with stroke. In Study II the sample size was based on the qualitative aim to achieve an in-depth understanding (83); also, it was aimed to include all participants from the intervention group in Study I. In Study III the sample size of 81 persons was selected based on recommendations in the literature (59, 66, 67). The sample size in Study IV was based on the mixed method procedure (93). Priority was given to the qualitative data (83) and it was intended that both qualitative and quantitative data should be from the same population (93), ending in a relatively small quantitative data collection.

Data collection In all four studies the data collection was performed in a standardized order and the test protocol was followed carefully. In all studies the physiotherapists who participated in the data collection were specialized in neurological physiotherapy, with clinical experience in physiotherapy for patients with stroke. In Studies I and III, to strengthen the internal validity the physiotherapists were introduced to the study protocol, all the measuring instruments and the procedure. All conditions were kept as stable as possible. In Study I none of the physiotherapists performing the data collection participated in the intervention. They were not blinded, but they had no insight into the intervention. To increase the internal validity in Studies I and III, the same physiotherapists performed the retests, at the same location in an ordinary hallway at the primary health care centre, and around the same time of the day. A limitation of Study I was that there was no reflection on the participants’ activity habits between the test occasions. The participants were instructed not to change their activity habits between the test occasions. However, just to be part of an intervention study can increase overall activity level. In future studies, using an activity log or diary or an activity bracelet would be valuable, to receive further knowledge on any side activities. The intervention in Study I continued for 8 weeks. This time period was based on how physiotherapists in primary health care in the county usually conduct BAT, and was also selected for practical reasons such as


avoiding vacation periods and preventing high dropout rates. Longer interventions have been performed in one study by Gyllensten et al (41) and it is acknowledged that, to see changes over time, longer interventions may be needed. The selected movements were based on earlier BAT studies (39, 40) and the experience of the physiotherapists responsible for the intervention. All persons participating in the intervention in Study I, participated in the interviews in Study II. This can be seen as a strength; first, as both negative and positive experiences of BAT thus could be captured and, secondly, as the level of functioning after stroke differed between the individuals, a broad perspective of experiences could be reached.

Data analysis In Study II, two out of the three authors (M.L.A.L) and (A.F) had a pre-understanding as physiotherapists in stroke rehabilitation, (A.A.C) is a registered nurse, experienced in qualitative methods. Studies III and IV also included a neurologist specialized in stroke (P.A). The mixed experience of the researchers may increase the credibility of the findings (116, 117) as it likely brought a broad perspective to the analysis. Throughout the qualitative analysis procedure, to support trustworthiness (83, 104, 116) the results were discussed and reflected on in a back and forth process and all authors were engaged in the data analysis in various steps. The analysis was performed in both the software programs Microsoft Word (Microsoft Corp., Seattle, WA, USA)’and NVivo 11 (QSP International, Victoria, Australia). There are strengths and limitations with both. The analysis process is presented both in the text and in figures, with meaning units, categories and themes given. Quotes have been presented to support the text and further enhance the credibility of the study (83).


53

CONCLUSION In summary, the pilot study evaluating effects of BAT in persons with stroke showed no significant differences in balance, mobility, balance confidence, and subjective health status after 8 weeks of BAT compared with an control group. According to the patients’ and physiotherapists’ narratives, exercising with BAT was simple but challenging. Experiences of improved balance as well as feelings of harmony were reported. However, further studies are needed to determine optimal intensity of intervention, exercises and outcome measures. The SSST includes a weight shift in combination with a dual-task activity during walking, thus being a challenging instrument for persons with balance impairment after stroke. The SSST showed strong convergent validity with other instruments of gait and balance. The findings in this study suggest that the SSST can be used as a complementary measure of walking balance in stroke rehabilitation although sensitivity to changes over time must be further investigated. Persons with balance limitations after stroke related that they were able to manage their life, although this could at times be challenging. Evaluation of balance during walking and self-rated balance confidence complemented the subjective narratives of living with balance limitations. The participants related that everyday life was challenged by the continuous feeling of dizziness and instability.


Clinical implications • Body Awareness Therapy can be a complement in

physiotherapeutic stroke rehabilitation; however, further studies are needed to establish optimal intensity and length of the therapy, as well as determine outcome measures.

• Body Awareness Therapy includes simple but challenging

exercises that can be individually adjusted and are possible to perform for persons who have had a stroke.

• The Six-spot Step test can be a complementary measure of walking balance in stroke rehabilitation. It includes a dual-task activity and also has a game like aspect.

• To get a fuller picture of balance and an assessment of balance among persons who have had a stroke, perceived and measured balance can give valuable information. However, for an accurate description, this information should be complemented by asking these persons about their experiences and challenges.


55

SAMMANFATTNING PÅ SVENSKA (Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures) Stroke är den vanligaste orsaken till neurologisk funktionsnedsättning hos vuxna. Stroke är ett samlingsnamn för hjärninfarkt och hjärnblödning. I Sverige är det ca 25 000-30 000 som får stroke varje år. Nedsatt motorisk funktion i form av bl.a. nedsättning av balans och gångfunktion är vanligt efter stroke. Andra orsaker som kan påverka balans och gångfunktion är nedsatt sensorisk funktion, synnedsättning, spasticitet samt nedsatt kognitiv förmåga. Det övergripande målet med strokerehabilitering är att personen ska kunna leva ett aktivt liv och kunna delta i samhället. Rehabiliteringen bör vara individualiserad och uppgiftsspecifik. Oavsett funktionsnivå kan förbättring av funktion ske månader och år efter insjuknandet. Den fysioterapeutiska behandlingen syftar bland annat till att förbättra gångförmåga och balans samt till att förebygga fall. Att förbättra gångförmågan är något många drabbade skattar som det viktigaste efter en stroke. Det finns olika metoder att träna balans, men det saknas dock evidens för att någon specifik behandlingsmetod är mer effektiv än någon annan. För att mäta förändring av balans behövs valida och reliabla mätinstrument, avsedda för den specifika patientgruppen och anpassade till kontext. Det finns studier som mäter tillit och tilltro till balans, men det finns få studier där patienterna själv beskriver sin upplevelse av balans. För att rehabiliteringen av personer med funktionsnedsättning efter stroke ska bli så optimal som möjligt är det betydelsefullt att lyssna på patientens behov och önskningar, och det är därför viktigt att lyfta fram patienternas perspektiv. Det övergripande syftet i doktorandprojektet var att undersöka och beskriva olika aspekter av balans hos personer som fått en stroke; avseende träning, mätinstrument, och upplevd balans. I Studie I undersöktes effekter av basal kroppskännedomsträning, i syfte att träna balans. Det är en metod som tidigare inte använts i behandling personer med stroke. Basal kroppskännedom är en metod med enkla rörelseövningar med fokus på rörelsekvalitet, kroppsmedvetenhet och rörelsebeteende. Centralt är att hitta en inre mittlinje i kroppen och utifrån den utföra olika övningar som t.ex. tyngdöverföringar, hållningsövningar, rotationer runt mittlinjen och samtidigt ha en fri andning. Av de 46 personer som tackat ja att delta i studien lottades 24 till träningsgrupp


med basal kroppkännedom och 22 till kontrollgrupp. Mellan grupperna fanns det inga signifikanta skillnader över tid avseende balansförmåga, tilltro till balans och subjektivt upplevd hälsa. Avseende utfall fanns signifikanta förbättringar över tid inom träningsgruppen för 4 av 7 mätinstrument och inom kontrollgruppen för 3 av 7 mätinstrument. Personerna som deltog i träningsgruppen erbjöds även att delta i studie II, en intervju studie, med syftet att beskriva upplevelsen av 8 veckor av basal kroppkännedom med utgångspunkt från både personerna med stroke, samt fysioterapeutens perspektiv. Intervjuerna fokuserade på personernas upplevelse av behandlingen med basal kroppskännedom. Instruktörerna i basal kroppskännedom (fysioterapeuter) intervjuades i par, de övriga individuellt. Resultatet presentarades i ett huvudtema ”Simple yet challenging” som baserades på sex kategorier. Både deltagarna och fysioterapeuterna upplevde att balansen utmanades och att träningen gav möjligheter att reflektera över kroppen och dess funktion. I Studie III undersöktes validitet och reliabilitet för Six-Spot Step Test (SSST) hos personer med stroke. SSST ger en objektiv mätning av balans, och är utvecklat samt validerat för personer med multipel skleros, men inte för personer med stroke. SSST är ett mätinstrument där personen utför tyngdöverföringar i aktivitet, genom att gå 6 meter och sparka omkull fem klossar med ett ben i taget. Testet avspeglar sensomotoriska funktioner som styrka av nedre extremitet, spasticitet och koordination och balans samt till en viss del syn och kognition. En tvärsnittsstudie med mätning av postural stabilitet och gång, samt en upprepad mätning efter en vecka genomfördes. Samstämmighet av SSST mättes genom korrelation med validerade gång- och balans instrument; Activities-specific Balance Confidence scale (ABC-skalan), Timed Stands Test, Four Square Step Test, Dynamic Gait Index och Timed Up and Go. SSST visade sig ha god validitet och reliabilitet, men det fanns en begränsad känslighet vid upprepade mätningar. I Studie IV var fokus på upplevelsen av balans efter stroke. Syftet var att beskriva balans hos personer som fått en stroke, med utgångspunkt i upplevd påverkan i dagligt liv, självskattad balans samt balans mätt med validerat mätinstrument. Studien hade en deskriptiv studiedesign, med mixed methods som innebar en semistrukturerarad intervju, objektivt mätt balans med SSST samt självskattad balans med ABC-skalan. Resultatet presenterades i två teman baserade på sju kategorier. Personerna upplevde att balansen var en ständig utmaning, med yrsel och ostadighet, men ändå så klarade de sin vardag. De tre olika datainsamlingsmetoderna, fångade delvis olika aspekter på balans hos


57

personer med stroke, resultaten kompletterade varandra, några bekräftade varandra, men inga resultat var direkt motsägelsefulla. Ett genomgående mönster i alla kategorier var att nästan alla personer var representerade i alla kategorer. Genom att använda olika datainsamlingsmetoder så har i avhandlingen framkommit olika aspekter på balans. Träning med basal kroppskännedom i 8 veckor gav ingen statistisk säkerställd skillnad gällande balansförmåga mellan grupperna. Personerna med stroke och fysioterapeuterna beskrev att balansen utmanades av basal kroppkännedom och att träningen gav möjligheter till att reflektera över kroppen och dess funktion. För personer med stroke så hade SSST ha god validitet och reliabilitet med en begränsad känslighet vid upprepade mätningar. Personerna med stroke upplevde att balansen var en utmaning men att de lyckades hantera sitt vardagliga liv. Den objektiva och den självskattade balansmätningen kompletterade den subjektiva upplevelsen att leva med balans nedsättning.


ACKNOWLEDGEMENT This work was carried out at the Faculty of Medicine and Health, Örebro University and the University Health Care Research Centre, Örebro, Sweden. I wish to express my warmest gratitude to all those who have helped and supported me throughout this thesis. I could not have completed this on my own. Special thanks are due to: All the persons with stroke who generously contributed their time to make this thesis possible. Anette Forsberg, my main supervisor for your enormously engagement. Thank you for guiding me in the academic world with your great knowledge, all the time you spent for supervision and your patience. Agneta Anderzén Carlsson, my supervisor for your positive approach and for your firm belief that everything will work out to the best. Without you article II have never been finished never been “simple yet challenging”. Peter Appelros my supervisor for your elegant and valuable comments on writing and your great knowledge in stroke. Margareta Möller Professor, head of department of the University Health Care Research Center (UFC), for giving me the opportunity to be part of your creative research environment. Kumla vårdcentral, with Annika Roman and Lennart Svärd for support during all these years. All colleges at the Rehabilitation department at Kumla healthcare centre for your always positive attitudes and your tolerance with me popping in some days at the week. Peter Engfeldt head of department at the former Allmänmedicinskt forskningscentrum, who made it possible for me to start this journey in the academic world. The Medical Library, USÖ and Birgitta Eriksson for all your help with the Endnote, databases searches and requires of articles.


59

The Neurophysiotherapists group, Helena Tholin, Steven Allen, Anna Lövgren, Nicklas Borgkvist and Ewa Pettersson, my colleagues in the primary health care. For support and practical help. Martin Eriksson Crommert for your enormous valuable ability to explain and guide me in wonderful world of statistics. Always with a smile! The running team at UFC; Marie Matérne, Emma Nilsing Strid, Lars Hagberg, Anna Duberg and Karin Hilden for connecting running and research in a much higher level. After a run no scientific mountain is too high or too step. To all my research colleges at University Healthcare Research Centre, for all the enjoyable seminaries and for support making my doctoral student period a pleasant journey. Especially thanks to former and present doctoral students Anna Carling, Cecilia Bergh, Kristina Luhr and Anna Philipsson. Susanne Collgård for assistance when the computer and I didn’t understand each other and for bringing a peaceful atmosphere of just being you. Miriam Pikkemaat from the National research school in general practice for sharing and cheering both science and running. Elisabeth Westerdahl for traveling companions in many dimensions! For financial support, the Swedish Stroke Association, The Neurology Section from the Swedish Association of Physiotherapists, Norrbacka- Eugenia Foundation, and the Research Committee, Örebro County Council Friends for always being there and for helping me getting things into perspective, not always knowing what I was doing but supported anyhow. My parents in law, for your never ending of support in practical help as babysitting and just everyday life struggles.


My parents Thage and Lisbeth because you encouraged me to do what I want in life and always supported it. Thank you for always being there. My French parents for having a second home in the mountain where I can reload my batteries. My sisters Sophia and Gry, we help and encourages each other. We will always do! My husband Henrik, this has not been possible without you. We did it! Olle och Nisse, mina hjältar. Jag är så stolt, glad och lycklig över att vara er mamma.


61

REFERENCES

1. Feigin VL, Mensah GA, Norrving B, Murray CJ, Roth GA. Atlas of the Global Burden of Stroke (1990-2013): The GBD 2013 Study. Neuroepidemiology. 2015;45(3):230-6.

2. World Health Organization. Cerebrovascular accident 2016 [updated 20160602; cited 20180312]. Available from: http://www.who.int/topics/cerebrovascular_accident/en/.

3. WHO Task Force on Stroke and Other Cerebrovascular Disorders. Stroke--1989. Recommendations on stroke prevention, diagnosis, and therapy. Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke. 1989;20(10):1407-31.

4. Folkhälsomyndigheten. Folkhälsorapportering och statistik, folkhälsans utveckling, insjuknande i stroke 2016 [cited 20180107]. Available from: https://www.folkhalsomyndigheten.se/folkhalsorapportering-statistik/folkhalsans-utveckling/halsa/insjuknande-i-stroke/.

5. Riksstroke. The Swedish Stroke Register 2016 [cited 20180107]. Available from:http://www.riksstroke.org/sve/patient-och-narstaende/stroke/.

6. Socialstyrelsen. Nationella riktlinjer för strokesjukvård Stockholm: Socialstyrelsen; 2017 [updated 20170522; cited 20180107]. Available from: https://roi.socialstyrelsen.se/riktlinjer/nationella-riktlinjer-for-vard-vid-stroke.

7. Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. The Cochrane database of systematic reviews. 2014;4:CD001920.

8. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet neurology. 2009;8(8):741-54.


9. Kamphuis JF, de Kam D, Geurts AC, Weerdesteyn V. Is weight-bearing asymmetry associated with postural instability after stroke? A systematic review. Stroke Res Treat. 2013;2013:692137.

10. Pollock C, Eng J, Garland S. Clinical measurement of walking balance in people post stroke: a systematic review. Clin Rehabil. 2011;25(8):693-708.

11. Van de Port IG, Kwakkel G, Schepers VP, Lindeman E. Predicting mobility outcome one year after stroke: a prospective cohort study. J Rehabil Med. 2006;38(4):218-23.

12. An HJK, J. I. Kim, Y. R. Lee, K. B. Kim, D. J. Yoo, K. T. Choi, J. H. The effect of various dual task training methods with gait on the balance and gait of patients with chronic stroke. J Phys Ther Sci. 2014;26(8):1287-91.

13. Dennis A, Dawes H, Elsworth C, Collett J, Howells K, Wade DT, et al. Fast walking under cognitive-motor interference conditions in chronic stroke. Brain Res. 2009;1287:104-10.

14. Hendrickson J, Patterson KK, Inness EL, McIlroy WE, Mansfield A. Relationship between asymmetry of quiet standing balance control and walking post-stroke. Gait Posture. 2014;39(1):177-81.

15. Kamphuis JF, de Kam D, Geurts AC, Weerdesteyn V. Is weight-bearing asymmetry associated with postural instability after stroke? A systematic review. Stroke research and treatment. 2013;2013:692137.

16. Kwakkel G, Kollen B, Lindeman E. Understanding the pattern of functional recovery after stroke: facts and theories. Restor Neurol Neurosci. 2004;22(3-5):281-99.

17. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. The Lancet. 2011;377(9778):1693-702.

18. Richards CL, Malouin F, Dean C. Gait in stroke: assessment and rehabilitation. Clin Geriatr Med. 1999;15(4):833-55.


63

19. Shumway-Cook A, Woollacott MH. Motor Control : translating research into clinical practice. Motor Control. 4 ed. Baltimore: Lippincott Williams & Wilkins; 2012.

20. Pollock AS, Durward BR, Rowe PJ, Paul JP. What is balance? Clin Rehabil. 2000;14(4):402-6.

21. Langhammer B, Lindmark B. Functional exercise and physical fitness post stroke: the importance of exercise maintenance for motor control and physical fitness after stroke. Stroke Res Treat. 2012;2012:864835.

22. The World Confederation for Physical Therapy WCPT. Policy statement: Description of physical therapy 2015 [cited 20180107]. Available from: http://www.wcpt.org/policy/ps-descriptionPT

23. World Health Organization. Definition Rehabilitation Geneva: WHO; 2012 [cited 20180107]. Available from: http://www.who.int/topics/rehabilitation/en/.

24. Weerdesteyn V, De Niet M, Van Duijnhoven HJ, Geurts AC. Falls in individuals with stroke. J Rehabil Res Dev. 2008;45(8):1195-213.

25. Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil. 2000;81(4):409-17.

26. Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Cote R. A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. Clin Rehabil. 2004;18(5):509-19.

27. Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, et al. Physical fitness training for stroke patients. Cochrane Database Syst Rev. 2016;3:Cd003316.

28. Teixeira-Salmela LF, Olney SJ, Nadeau S, Brouwer B. Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors. Arch Phys Med Rehabil. 1999;80(10):1211-8.


29. van de Port IG, Wood-Dauphinee S, Lindeman E, Kwakkel G. Effects of exercise training programs on walking competency after stroke: a systematic review. Am J Phys Med Rehabil. 2007;86(11):935-51.

30. Van Peppen RP, Kwakkel G, Wood-Dauphinee S, Hendriks HJ, Van der Wees PJ, Dekker J. The impact of physical therapy on functional outcomes after stroke: what's the evidence? Clin Rehabil. 2004;18(8):833-62.

31. Yang YR, Wang RY, Lin KH, Chu MY, Chan RC. Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clin Rehabil. 2006;20(10):860-70.

32. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev. 2013(9):Cd000197.

33. Ferrarello F, Baccini M, Rinaldi LA, Cavallini MC, Mossello E, Masotti G, et al. Efficacy of physiotherapy interventions late after stroke: a meta-analysis. J Neurol Neurosurg Psychiatry. 2011;82(2):136-43.

34. Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review. Clin Rehabil. 2007;21(5):395-410.

35. Salbach NM, Mayo NE, Robichaud-Ekstrand S, Hanley JA, Richards CL, Wood-Dauphinee S. Balance self-efficacy and its relevance to physical function and perceived health status after stroke. Arch Phys Med Rehabil. 2006;87(3):364-70.

36. Schmid AA, Van Puymbroeck M, Altenburger PA, Dierks TA, Miller KK, Damush TM, et al. Balance and balance self-efficacy are associated with activity and participation after stroke: a cross-sectional study in people with chronic stroke. Arch Phys Med Rehabil. 2012;93(6): 1101-7.

37. English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database Syst Rev. 2017;6:Cd007513.


65

38. Pollock A, Baer G, Pomeroy V, Langhorne P. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. Cochrane Database Syst Rev. 2003(2):CD001920.

39. Dropsy J. The harmonious body (Den harmoniska kroppen). Stockholm: Natur och Kultur; 1988.

40. Roxendal G. Body awereness Therapy and Body Awereness Scale, treatment and evaluation in psychiatric physiotherapy. Göteborg: Göteborgs universitet; 1985.

41. Gyllensten AL, Hansson L, Ekdahl C. Outcome of Basic Body Awareness Therapy. A Randomized Controlled Study of Patients in Psychiatric Outpatient Care. Advances in Physiotherapy. 2003;5(4):179-90.

42. Hedlund L, Gyllensten AL. The experiences of basic body awareness therapy in patients with schizophrenia. J Bodyw Mov Ther. 2010;14(3):245-54.

43. Gard G. Body awareness therapy for patients with fibromyalgia and chronic pain. Disabil Rehabil. 2005;27(12):725-8.

44. Sjodahl C, Jarnlo GB, Persson BM. Gait improvement in unilateral transfemoral amputees by a combined psychological and physiotherapeutic treatment. J Rehabil Med. 2001;33(3):114-8.

45. Catalan-Matamoros D, Helvik-Skjaerven L, Labajos-Manzanares MT, Martinez-de-Salazar-Arboleas A, Sanchez-Guerrero E. A pilot study on the effect of Basic Body Awareness Therapy in patients with eating disorders: a randomized controlled trial. Clin Rehabil. 2011;25(7): 617-26.

46. Eriksson EM, Moller IE, Soderberg RH, Eriksson HT, Kurlberg GK. Body awareness therapy: a new strategy for relief of symptoms in irritable bowel syndrome patients. World J Gastroenterol. 2007;13(23):3206-14.


47. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8.

48. Fulk GD, Echternach JL, Nof L, O'Sullivan S. Clinometric properties of the six-minute walk test in individuals undergoing rehabilitation poststroke. Physiother Theory Pract. 2008;24(3):195-204.

49. Graham JE, Ostir GV, Fisher SR, Ottenbacher KJ. Assessing walking speed in clinical research: a systematic review. J Eval Clin Pract. 2008;14(4):552-62.

50. Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications. 2 ed. Baltimore: Williams & Wilkins; 1995.

51. Myers AM, Powell LE, Maki BE, Holliday PJ, Brawley LR, Sherk W. Psychological indicators of balance confidence: relationship to actual and perceived abilities. J Gerontol A Biol Sci Med Sci. 1996;51(1):M37-43.

52. Tinetti ME, Richman D, Powell L. Falls efficacy as a measure of fear of falling. J Gerontol. 1990;45(6):P239-43.

53. Durcan S, Flavin E, Horgan F. Factors associated with community ambulation in chronic stroke. Disabil Rehabil. 2016;38(3):245-9.

54. Schinkel-Ivy A, Wong JS, Mansfield A. Balance Confidence Is Related to Features of Balance and Gait in Individuals with Chronic Stroke. J Stroke Cerebrovasc Dis. 2017;26(2):237-45.

55. Torkia C, Best KL, Miller WC, Eng JJ. Balance Confidence: A Predictor of Perceived Physical Function, Perceived Mobility, and Perceived Recovery 1 Year After Inpatient Stroke Rehabilitation. Arch Phys Med Rehabil. 2016;97(7):1064-71.

56. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83 Suppl 2:S7-11.


67

57. Mao HF, Hsueh IP, Tang PF, Sheu CF, Hsieh CL. Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke. 2002;33(4):1022-7.

58. Jonsdottir J, Cattaneo D. Reliability and validity of the dynamic gait index in persons with chronic stroke. Arch Phys Med Rehabil. 2007;88(11):1410-5.

59. Flansbjer UB, Holmback AM, Downham D, Patten C, Lexell J. Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37(2):75-82.

60. Nieuwenhuis MM, Van Tongeren H, Sorensen PS, Ravnborg M. The six spot step test: a new measurement for walking ability in multiple sclerosis. Mult Scler. 2006;12(4):495-500.

61. Brogardh C, Flansbjer UB, Lexell J. Self-reported walking ability in persons with chronic stroke and the relationship with gait performance tests. PM R. 2012;4(10):734-8.

62. Outermans J, Pool J, van de Port I, Bakers J, Wittink H. What's keeping people after stroke from walking outdoors to become physically active? A qualitative study, using an integrated biomedical and behavioral theory of functioning and disability. BMC Neurol. 2016;16(1):137.

63. Simpson LA, Eng JJ, Tawashy AE. Exercise perceptions among people with stroke: Barriers and facilitators to participation. Int J Ther Rehabil. 2011;18(9):520-30.

64. Schmid A, Rittman M. Fear of Falling: An Emerging Issue After Stroke. Top Stroke Rehabil. 2007;14:46-55.

65. Walsh M, Galvin R, Horgan NF. Fall-related experiences of stroke survivors: a meta-ethnography. Disabil Rehabil. 2017;39(7):631-40.

66. Flansbjer UB, Blom J, Brogardh C. The reproducibility of Berg Balance Scale and the Single-leg Stance in chronic stroke and the relationship between the two tests. PM R. 2012;4(3):165-70.


67. Hopkins WG. Measures of reliability in sports medicine and science. Sports Med. 2000;30(1):1-15.

68. Creswell WJ. A Concise Introduction to Mixed Method: Sage Publications Inc; 2014.

69. Lyden P, Brott T, Tilley B, Welch KM, Mascha EJ, Levine S, et al. Improved reliability of the NIH Stroke Scale using video training. NINDS TPA Stroke Study Group. Stroke. 1994;25(11):2220-6.

70. Newcomer KL, Krug HE, Mahowald ML. Validity and reliability of the timed-stands test for patients with rheumatoid arthritis and other chronic diseases. J Rheumatol. 1993;20(1):21-7.

71. Csuka M, McCarty DJ. Simple method for measurement of lower extremity muscle strength. Am J Med. 1985;78(1):77-81.

72. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992;83(Suppl 2):S7-11.

73. Hofheinz M, Mibs M. The Prognostic Validity of the Timed Up and Go Test With a Dual Task for Predicting the Risk of Falls in the Elderly. Gerontol Geriatr Med. 2016;2:2333721416637798.

74. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903.

75. Blennerhassett JM, Jayalath VM. The Four Square Step Test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people poststroke. Arch Phys Med Rehabil. 2008;89(11):2156-61.

76. Goh EY, Chua SY, Hong SJ, Ng SS. Reliability and concurrent validity of Four Square Step Test scores in subjects with chronic stroke: a pilot study. Arch Phys Med Rehabil. 2013;94(7):1306-11.

77. Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002;83(11):1566-71.


69

78. Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the activities-specific balance confidence (ABC) scale. J Gerontol A Biol Sci Med Sci. 1998;53(4):M287-94.

79. Forsberg A, Nilsagard Y. Validity and Reliability of the Swedish Version of the Activities-specific Balance Confidence Scale in People with Chronic Stroke. Physiother Can. 2013;65(2):141-7.

80. Persson LO, Karlsson J, Bengtsson C, Steen B, Sullivan M. The Swedish SF-36 Health Survey II. Evaluation of clinical validity: results from population studies of elderly and women in Gothenborg. J Clin Epidemiol. 1998;51(11):1095-103.

81. Sullivan M, Karlsson J, Ware JE, Jr. The Swedish SF-36 Health Survey--I. Evaluation of data quality, scaling assumptions, reliability and construct validity across general populations in Sweden. Soc Sci Med. 1995;41(10):1349-58.

82. Kvale S. Interviews: An Introduction to Qualitative Research Interviewing: Sage Publications; 1996.

83. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12.

84. Andresen EM. Criteria for assessing the tools of disability outcomes research. Arch Phys Med Rehabil. 2000;81(12 Suppl 2):S15-20.

85. Portney LG, Watkins MP. Foundations of Clinical Research application to practice 3ed: Pearson Education (US); 2007.

86. Lexell JE, Downham DY. How to assess the reliability of measurements in rehabilitation. Am J Phys Med Rehabil. 2005;84(9):719-23.

87. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;86(2):420-8.

88. Bland JM, Altman DG. Measurement error. BMJ. 1996;313(7059):744.


89. Beckerman H, Roebroeck ME, Lankhorst GJ, Becher JG, Bezemer PD, Verbeek AL. Smallest real difference, a link between reproducibility and responsiveness. Qual Life Res. 2001;10(7):571-8.

90. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1(8476):307-10.

91. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8(2):135-60.

92. Huang SL, Hsieh CL, Wu RM, Tai CH, Lin CH, Lu WS. Minimal detectable change of the timed "up & go" test and the dynamic gait index in people with Parkinson disease. Phys Ther. 2011;91(1): 114-21.

93. Creswell WJ, Plano LV. Designing and conducting mixed method research. United States of America: SAGE publications, Inc.; 2011.

94. World Medical Association. Declaration of Helsinki-etical principels for medical research involvnig human subjects. 2017 [cited 20180412].

95. Vetenskapsrådet. Etikprövning; Forskning på människor (The Swedish research council) (Etical approval; research in humans) (in Swedish). Stockholm2015 [cited 20180312].

96. Patton M. Qualitative research and evaluation methods. 3.ed ed. London: SAGE; 2002.

97. Bang DH, Cho HS. Effect of body awareness training on balance and walking ability in chronic stroke patients: a randomized controlled trial. J Phys Ther Sci. 2016;28(1):198-201.

98. Bang DH, Noh HJ, Cho HS. Effects of body awareness training on mild visuospatial neglect in patients with acute stroke: a pilot randomized controlled trial. J Phys Ther Sci. 2015;27(4):1191-3.

99. Mannerkorpi K, Arndorw M. Efficacy and feasibility of a combination of body awareness therapy and qigong in patients with fibromyalgia: a pilot study. J Rehabil Med. 2004;36(6):279-81.


71

100. Wohlin Wottrich A, Stenstrom CH, Engardt M, Tham K, von Koch L. Characteristics of physiotherapy sessions from the patient's and therapist's perspective. Disabil Rehabil. 2004;26(20):1198-205.

101. Hedlund L, Gyllensten AL. The physiotherapists' experience of Basic Body Awareness Therapy in patients with schizophrenia and schizophrenia spectrum disorders. J Bodyw Mov Ther. 2013;17(2):169-76.

102. Gyllensten AL, Hansson L, Ekdahl C. Patient experiences of basic body awareness therapy and the relationship with the physiotherapist. J Bodyw Mov Ther. 2003;7(3): 173-83.

103. Banks G, Bernhardt J, Churilov L, Cumming TB. Exercise preferences are different after stroke. Stroke Res Treat. 2012;2012:890946.

104. Polit D, Beck TC. Nursing Research. Generating and assessing evidence for nursing practice.: Lillpincott Williams & Wilkkins, a Wolter Kluwer business; 2008.

105. Streiner DL, G.R. N. Health measurement scales a practical guide to their development and use. Oxford New york: Oxford university press; 2008.

106. An HJ, Kim JI, Kim YR, Lee KB, Kim DJ, Yoo KT, et al. The effect of various dual task training methods with gait on the balance and gait of patients with chronic stroke. J Phys Ther Sci. 2014;26(8):1287-91.

107. Plummer P, Eskes G, Wallace S, Giuffrida C, Fraas M, Campbell G, et al. Cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research. Arch Phys Med Rehabil. 2013;94(12):2565-74 e6.

108. Fritz NE, Jiang A, Keller J, Zackowski KM. Utility of the Six-Spot Step Test as a Measure of Walking Performance in Ambulatory Individuals With Multiple Sclerosis. Arch Phys Med Rehabil. 2016;97(4):507-12.

109. Pavan K, Tilbery CP, Lianza S, Marangoni BE. Validation of the "Six Step Spot Test" for gait among patients with multiple sclerosis in Brazil. Arq Neuropsiquiatr. 2010;68(2):198-204.


110. Sandroff BM, Motl RW, Sosnoff JJ, Pula JH. Further validation of the Six-Spot Step Test as a measure of ambulation in multiple sclerosis. Gait Posture. 2015;41(1):222-7.

111. Callesen J, Richter C, Kristensen C, Sunesen I, Naesby M, Dalgas U, et al. Test-retest agreement and reliability of the Six Spot Step Test in persons with multiple sclerosis. Mult Scler. 2017:1352458517745725.

112. Lo Buono V, Corallo F, Bramanti P, Marino S. Coping strategies and health-related quality of life after stroke. J Health Psychol. 2017;22(1):16-28.

113. Ostir GV, Berges I, Ottenbacher M, Graham JE, Ottenbacher KJ. Positive emotion following a stroke. J Rehabil Med. 2008;40(6):477-81.

114. Yiu J, Miller WC, Eng JJ, Liu Y. Longitudinal analysis of balance confidence in individuals with stroke using a multilevel model for change. Neurorehabil Neural Repair. 2012;26(8):999-1006.

115. Kubina LA, Dubouloz CJ, Davis CG, Kessler D, Egan MY. The process of re-engagement in personally valued activities during the two years following stroke. Disabil Rehabil. 2013;35(3): 236-43.

116. Lincoln YS GE. Naturalistic Inquiry. London: Sage Publications Inc; 1985.

117. Patton M. Integrating Theory and Practice. 4 ed: Sage Publications Inc; 2014.

Publications in the series Örebro Studies in Care Sciences*

1. Gustafsson, Margareta (2003) Konsekvenser av en akut traumatisk handskada. En prospektiv studie av patientens situation under det första året efter olyckan. Doktorsavhandling/Doctoral thesis with focus on Nursing.

2. Jackson, Karin (2005) Att vara förälder till ett för tidigt fött barn – en prospektiv studie om upplevelsen av föräldraskap och möten med vården. Doktorsavhandling/Doctoral thesis with focus on Nursing.

3. Odencrants, Sigrid (2005) Måltidsrelaterade situationer och näringstillstånd ur patienters med kroniskt obstruktiv lungsjukdom och sjuksköterskors perspektiv. Vetenskaplig uppsats för licentiatexamen/Academic essay.

4. Göransson, Katarina (2005) Emergency department triage – a challenging task for Swedish emergency nurses. Vetenskaplig uppsats för licentiatexamen/Academic essay.

5. Eldh, Ann Catrine (2005) Patienters upplevelser av och uttryck för fenomenet delaktighet i hälso- och sjukvård. Vetenskaplig uppsats för licentiatexamen/Academic essay.

6. Florin, Jan (2005) Clinical judgement in nursing – a collaborative effort? Patient participation and nurses’ knowledge. Vetenskaplig uppsats för licentiatexamen/Academic essay.

7. Ekwall, Ewa (2006) Women’s Experiences of Primary and Recurrent Gynecological Cancer. Vetenskaplig uppsats för licentiatexamen/Academic essay.

8. Pettersson, Ingvor (2006) Significance of Assistive Devices in the Daily Life of Persons with Stroke and Their Spouses. Doktors avhandling/Doctoral thesis with focus on Occupational Therapy.

9. Carlsson, Eva (2006) Understanding persons with eating difficulties and communication impairment after stroke – patient experiences and methodological issues in qualitative interviews. Vetenskaplig uppsats för licentiatexamen/Academic essay.

* Seriens namn var tidigare (nr 1–24) ”Örebro Studies in Caring Sciences”.

10. Göransson, Katarina (2006) Registered nurse-led emergency department triage: organisation, allocation of acuity ratings and triage decision making. Doktorsavhandling/Doctoral thesis with focus on Nursing.

11. Eldh, Ann Catrine (2006) Patient participation – what it is and what it is not. Doktorsavhandling/Doctoral thesis with focus on Nursing.

12. Isaksson, Ann-Kristin (2007) Chronic sorrow and quality of life in patients with multiple sclerosis. Doktorsavhandling/Doctoral thesis with focus on Nursing.

13. Florin, Jan (2007) Patient participation in clinical decision making in nursing – a collaborative effort between patients and nurses. Doktorsavhandling/Doctoral thesis with focus on Nursing.

14. Johansson, Agneta (2007) Adolescents’ perspective on mental health and health-promoting dialogues. Vetenskaplig uppsats för licentiatexamen/Academic essay.

15. Frisk, Margot (2007) Asthma and respiratory symptoms related to the housing environment. Doktorsavhandling/Doctoral thesis with focus on Occupational Therapy.

16. Forslund, Kerstin (2007) Challenges in prehospital emergency care – patient, spouse and personnel perspectives. Doktorsavhandling/Doctoral thesis with focus on Nursing.

17. Odencrants, Sigrid (2008) The complexity of nutritional status for persons with chronic obstructive pulmonary disease – a nursing challenge. Doktorsavhandling/Doctoral thesis with focus on Nursing.

18. Tollén, Anita (2008) Vardagen och förväntningar på dagrehabilitering – en studie i äldre personers uppfattningar. Vetenskaplig uppsats för licentiat examen/Academic essay.

19. Dwyer, Lise-Lotte (2008) Dignity in the end of life care – what does it mean to older people and staff in nursing homes? Doktorsavhandling/Doctoral thesis with focus on Nursing.

20. Lidskog, Marie (2008) Learning with, from and about each other: Inter professional education on a training ward in municipal care for older persons. Doktorsavhandling/Doctoral thesis.

21. Tinnfält, Agneta (2008) Adolescents’ perspectives – on mental health, being at risk, and promoting initiatives. Doktorsavhandling/Doctoral thesis with focus on Public Health.

22. Carlsson, Eva (2009) Communication about eating difficulties after stroke – from the perspectives of patients and professionals in health care. Doktorsavhandling/Doctoral thesis with focus on Nursing.

23. Källström Karlsson, Inga-Lill (2009) Att leva nära döden. Patienters och vårdpersonals erfarenheter inom hospicevård. Doktorsavhandling/Doctoral thesis with focus on Nursing.

24. Österlind, Jane (2009) När livsrummet krymper. Doktorsavhandling/ Doctoral thesis with focus on Nursing.

25. Liedström, Elisabeth (2009) Experiences of Chronic Sorrow and Quality of Life in Next of Kin of Patients with Multiple Sclerosis. Vetenskaplig uppsats för licentiatexamen/Academic essay.

26. Petersson, Pia (2009) Att göra abstrakta begrepp och komplexa situationer konkreta. En avhandling om deltagarbaserad aktions- forskning i svensk vård och omsorg. Doktorsavhandling/ Doctoral thesis with focus on Nursing.

27. James, Inger (2010) Bakom rutinerna. Kunskap och omvårdnads- praxis i mänskliga gränssituationer. Doktorsavhandling/ Doctoral thesis with focus on Nursing.

28. Thoroddsen, Ásta (2010) The role of standardised nursing languages in representing nursing and supporting nurses as knowledge workers. Doktorsavhandling/ Doctoral thesis with focus on Nursing.

29. Pettersson, Camilla (2010) Parents’ Possibility to Prevent Underage Drinking. Studies of Parents, a Parental Support Program, and Adolescents in the Context of a National Program to Support NGOs. Doktorsavhandling/ Doctoral thesis with focus on Public Health.

30. Rydlo, Cecilia (2010) Fighting for the otherness. Student nurses’ lived experiences of growing in caring. Doktorsavhandling/Doctoral thesis.

31. Ek, Kristina (2010) Att leva med mycket svår kronisk obstruktiv lungsjukdom – ett liv i slowmotion. Doktorsavhandling/Doctoral thesis.

32. Fröding, Karin (2011) Public Health, Neighbourhood Development, and Participation. Research and Practice in four Swedish Partnership Cities. Doktorsavhandling/Doctoral thesis.

33. Kollén, Lena (2011) Dizziness, balance and rehabilitiation in vestibular disorders. Doktorsavhandling/Doctoral thesis.

34. Wallerstedt, Birgitta (2012) Utmaningar, utsatthet och stöd i palliativ vård utanför specialistenheter. Doktorsavhandling/Doctoral thesis.

35. Ewertzon, Mats (2012) Familjemedlem till person med psykossjukdom: bemötande och utanförskap i psykiatrisk vård. Doktorsavhandling/Doctoral thesis.

36. Fossum, Mariann (2012) Computerized Decision Support System in Nursing Homes. Doktorsavhandling/Doctoral thesis.

37. Henriksson, Anette (2012) A support group programme for family members: an intervention during ongoing palliative care. Doktorsavhandling/Doctoral thesis.

38. Hälleberg Nyman, Maria (2012) Urinary catheter policies for short-term bladder drainage in hip surgery patients. Doktorsavhandling/Doctoral thesis.

39. Thorstensson, Stina (2012) Professional support in childbearing, a challenging act of balance. Doktorsavhandling/Doctoral thesis.

40. Geidne, Susanna (2012) The Non-Governmental Organization as a Health promoting Setting. Examples from Alcohol Prevention Projects conducted in the Context of National Support to NGOs. Doktorsavhandling/Doctoral thesis.

41. Lidström Holmqvist, Kajsa (2012) Occupational therapy practice for clients with cognitive impairment following acquired brain injury – occupational therapists’ perspective. Doktorsavhandling/Doctoral thesis.

42. Tollén, Anita (2013): Äldre personers dagliga liv och betydelsen av dagrehabilitering. Doktorsavhandling/Doctoral thesis.

43. Pajalic, Zada (2013): Matdistribution till hemmaboende äldre personer ur flera perspektiv. Doktorsavhandling/Doctoral thesis.

44. Olsson, Annakarin (2013): Daily life of persons with dementia and their spouses supported by a passive positioning alarm. Doktorsavhandling/Doctoral thesis.

45. Norell Pejner, Margaretha (2013): The bright side of life. Support in municipal elderly home care. Doktorsavhandling/Doctoral thesis.

46. Karlsson, Ulf (2013): Arbetsterapeuters attityd till och uppfattning om forskningsanvändning samt professionen ur ett manligt perspektiv. Vetenskaplig uppsats för licentiatexamen/Academic essay.

47. Salzmann-Erikson, Martin (2013): Caring in intensive psychiatry. Rhythm and movements in a culture of stability. Doktorsavhandling/Doctoral thesis.

48. Lindner, Helen (2013): The Assessment of Capacity for Myoelectric Control. Psychometric evidence and comparison with upper limb prosthetic outcome measures. Doktorsavhandling/Doctoral thesis.

49. Ohlsson-Nevo, Emma (2013): Colorectal cancer: Patients’ and next-of-kin’s experiences and the effects of a psycho-educational program. Doktorsavhandling/Doctoral thesis.

50. Falk-Brynhildsen, Karin (2013): The effect of preoperative skin preparation on bacterial growth during cardiac surgery. Doktorsavhandling/Doctoral thesis.

51. Jaensson, Maria (2013): Postoperative sore throat and hoarseness. Clinical studies in patients undergoing general anesthesia. Doktorsavhandling/Doctoral thesis.

52. Elisabeth Liedström (2014): Life Situation as Next of Kin to Persons in Need of Care: Chronic Sorrow, Burden and Quality of Life. Doktorsavhandling/Doctoral thesis.

53. Johansson, Anita (2014): Ändlös omsorg och utmätt hälsa: Föräldraskapets paradoxer när ett vuxet barn har långvarig psykisk sjukdom. Doktorsavhandling/Doctoral thesis.

54. Brobeck, Elisabeth (2014): Samtal som stöd för patienters livsstilsförändringar: en viktig del av sjuksköterskans hälsofrämjande arbete. Doktorsavhandling/Doctoral thesis.

55. Lindh, Marianne (2014): Adherence to hygiene routines in community care – the perspective of medically responsible nurses in Sweden. Vetenskaplig uppsats för licentiatexamen/Academic essay.

56. Källstrand-Eriksson, Jeanette (2014): Being on the trail of ageing.Functional visual ability and risk of falling in an increasingly ageing population. Doktorsavhandling/Doctoral thesis.

57. Jonny Geidne (2014): Implementation and Sustainability in a Swedish Setting Approach for Health Promotion-Research and Practice in four Partnership Cities. Vetenskaplig uppsats för licentiatexamen/Academic essay.

58. Ekwall, Eva (2009): Women’s Experiences of Gynecological Cancer and Interaction with the Health Care System through Different Phases of the Disease. Doktorsavhandling/Doctoral thesis.

59. Wätterbjörk, Inger (2014): Couples’ experiences of an information model about prenatal screening. Decision-making and satisfaction. Doktorsavhandling/Doctoral thesis.

60. Ek, Bosse (2014): Prioritering vid utlarmning i prehospital vård. Vetenskaplig uppsats för licentiatexamen/Academic essay.

61. Dahlkvist, Eva (2015): The Garden/Patio in Residential Care Facilities for Older People - Characteristics and the Users Perspectives. Vetenskaplig uppsats för licentiatexamen/Academic essay.

62. Faag, Carina (2015): A comprehensive nurse-led intervention for patients with peripheral vestibular disorders: the feasibility and benefits. Vetenskaplig uppsats för licentiatexamen/Academic essay.

63. Biswas, Animesh (2015): Maternal and Neonatal Death Review System to Improve Maternal and Neonatal Health Care Services in Bangladesh. Doktorsavhandling/Doctoral thesis.

64. Islam, Farzana (2016): Quality Improvement System for Maternal and Newborn Health Care Services at District and Sub-district Hospitals in Bangladesh. Doktorsavhandling/Doctoral thesis.

65. Algilani, Samal (2016): ”To be at one’s best” -The evolution of Opti-mal Functionality and its possible implementation in an ICT-platform. Doktorsavhandling/Doctoral thesis.

66. Fredriksson, Ingela (2016): Leisure-time youth-center as health-promotion settings. Vetenskaplig uppsats för licentiatexamen/Academic essay.

67. Larsson, Madelene (2016): Formal Female Mentoring Relationships as Health Promotion. Vetenskaplig uppsats för licentiatexamen/Academic essay.

68. Barzangi, Jir (2017): Infant Dental Enucleation in Sweden: Perspectives on a Practice among Residents of Eastern African Origin. Doktorsavhandling/Doctoral thesis.

69. Hugelius, Karin (2017): Disaster response for recovery: survivors’ experiences, and the use of disaster radio to promote health after natural disasters. Doktorsavhandling/Doctoral thesis.

70. Ewertsson, Mona (2017): Lärande av praktiska färdigheter inom sjuksköterskeprofessionen-studier av lärande i olika arenor. Doktorsavhandling/Doctoral thesis.

71. Sundqvist, Ann-Sofie (2017): Perioperative patient advocacy – having the patient’s best interests at heart. Doktorsavhandling/Doctoral thesis.

72. Rasoal, Dara (2017): Perspectives on Clinical Ethics Support and Ethically Difficult Situations: Reflections and Experiences. Doktorsavhandling/Doctoral thesis.

73. Wistrand, Camilla (2017): Swedish operating room nurses preventive interventions to reduce bacterial growth and surgical site infections, and to increase comfort in patients undergoing surgery. Doktorsavhandling/Doctoral thesis.

74. Luhr, Kristina (2018): Patient Participation from the Patient’s Preferences, That’s What Counts. Doktorsavhandling/Doctoral thesis.

75. Arvidsson Lindvall, Mialinn (2018): Physiotherapeutic perspectives on balance control after stroke: exercises, experiences and measures. Doktorsavhandling/Doctoral thesis.

Physiotherapeutic perspectives on balance control …1186992/FULLTEXT01.pdfBalance includes...

Documents

Transcript of Physiotherapeutic perspectives on balance control …1186992/FULLTEXT01.pdfBalance includes...