Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.
Design: We collected data via questionnaires for this cross-sectional study from general practice.
Setting: Primary health care in Norway.
Subjects: 1302 consecutive patients participated.
Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.
Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.
Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.
- Key Points
There was a high prevalence of reduced SRH in clinical general practice
Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH
These predictors are all modifiable with a potential to improve SRH
Method: Four databases were searched for studies published before August 2016 using database-specific keywords and synonyms for amputation, cardiovascular diseases and mobility. Assessment of the publications was performed based on predefined criteria; first title and abstract and thereafter the full text.
Results: Of the 1704 titles and abstracts, 51 full texts were assessed. Ten studies were included. Cardiovascular diseases were associated with cardiac complications during rehabilitation. Prosthetic training improved cardiac function. Seven studies showed that cardiovascular diseases were associated with a smaller chance of becoming a prosthetic walker, and with poorer mobility outcomes.
Conclusion: Evidence for effects of cardiovascular diseases on mobility in persons with a lower limb amputation is heterogeneous. Cardiovascular diseases reduce the chance of becoming a prosthetic walker and reduce mobility outcomes after a lower limb amputation. More research with adequate quality about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
- Implications for rehabilitation
Data about the effect of cardiovascular diseases on mobility in persons with a lower limb amputation is limited.
More research about cardiovascular diseases in persons requiring a lower limb amputation is needed, to enable informed choices in the pre- and post-amputation rehabilitation.
Method: An uncontrolled pre- and post-assessment design was employed to study the use of unmodified, low-cost, off-the-shelf smartphones combined with Internet-calendars as a compensatory memory strategy in community-dwelling patients with traumatic brain injury. Thirteen participants received a 6-week group-based intervention with pre-, post- and 2-month follow-up-assessments by questionnaires and by daily assessment of target behaviors for 2-week periods.
Results: Participants reported significantly fewer retro- and prospective memory problems on questionnaires after the intervention and at follow-up with large effect sizes. The performance of target behaviors, however, improved insignificantly with moderate effect sizes. There were no changes in quality of life or symptoms of emotional distress.
Conclusions: This study adds to a growing body of evidence that smartphones are a useful compensatory aid in rehabilitation of prospective memory that should routinely be considered in rehabilitation of traumatic brain injury patients.
- Implication for rehabilitation
Smartphones are easy-to-use and accessible assistive technology for compensatory memory rehabilitation to most traumatic brain injury patients.
By using low-cost, off-the-shelf devices, the technology becomes available to a broader range of patients.
By combining smartphones with Internet-based and cross-platform services (e.g., calendars, contacts) the participants are less device-dependent and less vulnerable to data loss.
Smartphones should routinely be considered as compensatory aid in rehabilitation of prospective memory of traumatic brain injured patients.
Materials and methods: A qualitative study using semi-structured interviews with 10 specialist physiotherapists in vestibular rehabilitation in three university teaching hospitals in England. Data were analyzed using thematic analysis.
Results: Four themes were identified: (i) The therapeutic relationship, (ii) Adapting assessment and treatment, (iii) Psychological intervention and support, and (iv) Physiotherapists’ education and training. Physiotherapists reported using a range of behavioral and cognitive techniques and adapting their therapeutic approach by placing greater emphasis on education, building trust and pacing treatment. Physiotherapists highlighted the need for more specialist psychological support for patients during vestibular rehabilitation and tailored training and guidance on addressing anxiety within vestibular rehabilitation.
Conclusions: Physiotherapists working in vestibular rehabilitation consider managing aspects of anxiety within their scope of practice and describe taking a psychosocial therapeutic approach. There is limited access to expert psychological support for patients with anxiety within vestibular rehabilitation.
- Implications for rehabilitation
Anxiety is strongly associated with vestibular disorders and it is common for these patients to be managed by physiotherapists in vestibular rehabilitation.
Vestibular rehabilitation services could improve access to psychological expertise through dedicated psychological input, more effective signposting and referral pathways, and better access to inter-professional support from psychologists and/or CBT practitioners in managing more complex patients.
Physiotherapists requested tailored training and guidance to enhance their ability to manage patients with anxiety more effectively in vestibular rehabilitation.
Design: A retrospective interrupted times series study.
Setting: Two multidisciplinary general practitioner (GP) practices.
Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.
Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.
Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.
Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.
Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.
- Key Points
An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting.
The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.
Design: We conducted focus groups (FGs) with 17 GPs.
Setting: Norwegian primary health care.
Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.
Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.
Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.
- KEY POINTS
Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:
There is a lack of preparation and formal training for the leadership role.
GPs experience tensions between the clinical and leadership role.
GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.
Design: Randomised survey study.
Setting: Denmark.
Subjects: A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population.
Interventions: A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination.
Main outcome measure: Self-reported intention to participate in cervical screening.
Results: A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3–17.6) and 7.7 (95% CI: 0.4–14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38).
Conclusions: Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination.
- KEY POINTS
Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information.
Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.
Method: The medical history of two HIV-positive patients with PML was reviewed; information on their neurological impairments, rehabilitation treatment and outcome was gathered.
Results: The patients, a 47-year-old married man and a 34-year-old single man, both suffered from dense right hemiplegia and motor aphasia. Their rehabilitation course was delayed and prolonged: they were suitable for intensive multidisciplinary rehabilitation only 8 months or more after the initial presentation. Their treatment in outpatient rehabilitation daycare three times a week, that lasted 7 months on average, resulted in slow and steady functional improvement. At the end of the rehabilitation treatment, both patients were living at home, able to express themselves, and able to walk independently with an assistive device. They remained with moderate disability (modified Rankin scale of 3).
Conclusion: PML patients require prolonged multidisciplinary rehabilitation treatment; however, considerable progress can be achieved.
- Implications for Rehabilitation
Progressive multifocal leukoencephalopathy (PML) is a disabling disease occurring in particular in the context of Human Immunodeficiency Virus (HIV).
Presently a growing number of HIV-positive PML patients eventually survive the disease and remain with severe neurological impairments.
PML patients require prolonged multidisciplinary rehabilitation treatment, and considerable progress can be achieved.
Design: A cross-sectional population study.
Setting: The municipality of Naestved, Denmark.
Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.
Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.
Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.
Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.
Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.
- KEY POINTS
Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.
Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.
Association of socioeconomic factors with pharmacotherapy was inconsistent.
Purpose: To determine whether young adults with transversal upper limb reduction deficiency (tULRD) have experienced limitations in various domains of participation during transition to adulthood and how they dealt with these limitations.
Participants: Fifteen participants (mean age 21.4 years) with tULRD.
Methods: A qualitative study was performed using a semi-structured interview based on the Rotterdam Transition Profile to identify the limitations experienced in participation domains.
Results: Almost all the participants reported difficulties in finding a suitable study or job. Most young adults were convinced they were suitable for almost any study or job, but their teachers and potential employers were more reserved. Few difficulties were reported on the domains leisure activities, intimate relationships/sexuality, housing/housekeeping and transportation. Participants preferred to develop their own strategies for dealing with limitations. Various aids, adaptations and prostheses were used to overcome limitations. Rehabilitation teams were infrequently consulted for advice in solving transitional problems.
Conclusion: Young adults with tULRD experience limitations mainly in choosing and finding a suitable study or job. Rehabilitation teams may play a more extensive role in supporting individuals with transitional problems.
- Implications for rehabilitation
Most young adults with transversal upper limb reduction deficiency (tULRD) experience limitations in study and job selection during transition to adulthood, but they do not consult the rehabilitation team.
Assessment of abilities in relation to job interests and practicing job specific bimanual activities may be helpful for young adults with a tULRD.
How the rehabilitation teams can meet the needs of young adults with tULRD during transitional phases, when autonomy is of growing importance, should be investigated further.
Methods: It was performed with an extensive literature review, mainly clinical practice guidelines, randomized controlled trials, reviews, focusing on the rehabilitation management.
Results: There are few clinical practice guidelines that address GHOA as a pathology with unique characteristics. Evidence based treatment recommendations are mostly supported by low-quality evidence and experts’ opinions, with few high levels of evidence studies guiding treatment decisions.
Conclusions: Despite the lack of good quality evidence, rehabilitation programs have proven to be efficient and reliable, and this revision provides information and recommendations in this field.
- Implication of Rehabilitation
Glenohumeral osteoarthritis is a common cause of pain and functional disability of the shoulder
There are few clinical practice guidelines that address Glenohumeral Osteoarthritis as a pathology with unique characteristics, and recommendations for rehabilitation and therapeutic exercise are poor
The paper provides current information on the characteristics of the disease, its rehabilitation process, and could be of interest for rehabilitation professionals to direct their practices in this field
Method: We conducted an outpatient two-part rehabilitation intervention that involved six weeks of therapeutic supervised training (part one) and six weeks of unsupervised training in a local gym following a training protocol (part two).
Results: Predefined feasibility objectives of safety (100%), consent rate (>80%), drop-out (<20%), adherence (>80%) and patient satisfaction (>80%) was achieved at part one. However, the failure to meet predefined feasibility objectives of drop-out, adherence and patient satisfaction of the unsupervised intervention at part two have led to a protocol revision for a future randomized controlled trial.
Conclusion: This study demonstrates that an intensive rehabilitation intervention of physical therapy and occupational therapy in the initial treatment phase of patients with gliomas whose Karnofsky performance status is ≥70 is safe and feasible, if relevant inclusion criteria and precautionary screening are made. With the revised protocol, we are confident that the foundation for conducting a successful randomized controlled trial among these vulnerable patients has been established.
- Implications for rehabilitation
Brain tumors constitute some of the most challenging cancer diagnoses presenting for rehabilitation intervention.
Patients with gliomas experiences limitations in physical functioning, cognition, and emotional wellbeing.
In a relatively small sample this study shows that supervised physical- and occupational therapy in patients with gliomas is safe and feasible in the initial treatment phase.
Patients with gliomas can potentially improve functioning through interdisciplinary rehabilitation
Design: Population-based questionnaire study.
Setting: Central Denmark Region with approximately 1.3 million inhabitants.
Subjects: All 843 active GPs in the Central Denmark Region were sent a questionnaire by mail.
Main outcome measures: Responses to 18 items concerning four aspects: provision of EOL care to patients with different diagnosis, confidence with being a key worker, organisation of EOL care and EOL skills (medical and psychosocial).
Results: In total, 573 (68%) GPs responded. Of these, 85% often/always offered EOL care to cancer patients, which was twice as often as to patients with non-malignancies (34–40%). Moreover, 76% felt confident about being a key worker, 60% had a proactive approach, and 58% talked to their patients about dying. Only 9% kept a register of patients with EOL needs, and 19% had specific EOL procedures. GP confidence with own EOL skills varied; from 55% feeling confident using terminal medications to 90% feeling confident treating nausea/vomiting. Increasing GP age was associated with increased confidence about being a key worker and provision of EOL care to patients with non-malignancies. In rural areas, GPs were more confident about administering medicine subcutaneously than in urban areas.
Conclusion: We found considerable diversity in self-reported EOL care competences. Interventions should focus on increasing GPs’ provision of EOL care to patients with non-malignancies, promoting better EOL care concerning organisation and symptom management.
- KEY POINTS
GPs are pivotal in end-of-life (EOL) care, but their involvement has been questioned. Hence, GPs’ perceived competencies were explored.
GPs were twice as likely to provide EOL care for patients with cancer than for patients with non-malignancies.
EOL care was lacking clear organisation in general practice in terms of registering palliative patients and having specific EOL procedures.
GPs were generally least confident with their skills in terminal medical treatment, for example, using medicine administered subcutaneously.
Method: Two focus groups, conducted with 15 rehabilitation professionals from various disciplines and working with people with disabilities of all ages were structured around two topics: (i) The usage of malls for rehabilitation and (ii) Factors that facilitate or limit rehabilitation professionals’ use of the mall as an environment for clinical assessment and/or intervention.
Results: The thematic analysis revealed that shopping malls were used to achieve several rehabilitation goals targeting physical and cognitive skills, psychological health and socialization. This real-life environment is motivating and helps foster independence and normalization. Factors affecting mall use during rehabilitation included personal factors (e.g. clients’ personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners).
Conclusion: Shopping malls may be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities.
- Implications for rehabilitation
To ensure successful community reintegration, clients could be trained at some point during their rehabilitation, to perform activities in real-life settings, such as a shopping mall.
Shopping malls appear to enable the attainment of rehabilitation goals targeting a variety of skills.
This real-life environment appears to be motivating and helps foster independence and normalization.
Factors felt to affect mall use during rehabilitation include personal factors (e.g. clients’ personality and level of readiness) and environmental factors (e.g. clinical context, accessibility of the mall and social attitudes of store owners).
The shopping mall may be an untapped resource as it appears to be a relevant rehabilitation assessment and treatment environment that could contribute to optimizing community integration of people with disabilities.
This observational cross-sectional study identifies features and occupational needs of complex inpatients during rehabilitation, focusing on function and ability, regardless of diagnosis.
Method: This study included sixteen adult inpatients with stroke, deemed complex according to Rehabilitation Complexity Scale-Extended, at admission to Rehabilitation ward (from July 2014 to February 2015). Patients with primary psychiatric disorders, language barriers, cognitive or severe communication deficits were excluded. Upon admission, a multidisciplinary team collected data on general health, independence in daily activities (Modified Barthel Index), fatigue (Fatigue Severity Scale), resistance to sitting and ability to perform instrumental activities (Instrumental Activities of Daily Living). The occupational therapist identified occupational needs according to Canadian Occupational Performance Measure.
Results: Inpatients enrolled in this study were dependent in basic ADL, limited in instrumental ADL and easily fatigable. Their occupational needs related to self-care (75%) and, to a lesser extent, productivity (15%) and leisure (10%). According to inpatients, rehabilitation process should firstly address self-care needs, followed by productivity and leisure problems.
Conclusions: Despite small sample size, this study described patterns of occupational needs in complex inpatients with stroke. These results will be implemented in client-centered rehabilitation programs to be tested in a phase-two trial. [NCT02173197]
- Implications for Rehabilitation
Priority occupational needs of complex inpatients with stroke during rehabilitation are focused on self-care area.
Productivity and leisure problems also arise in early post-acute phase.
Client-centered rehabilitation programs should firstly address self-care needs and, later on, they should also focus on the recovery of family and social roles.
Design: Total population-based case–control study.
Setting and subjects: 4562 cancer patients and 17,979 controls matched by age, sex, and primary care unit. Data were collected from the Swedish Cancer Register and the Regional Healthcare Database.
Method: We identified cancer patients in the Västra Götaland Region of Sweden diagnosed in 2011 with prostate, breast, colorectal, lung, gynaecological, and skin cancers including malignant melanoma. We studied the symptoms and diagnoses identified by diagnostic codes during a diagnostic interval of 12 months before the cancer diagnosis.
Main outcome measures: Consultation frequency, symptom density by cancer type, prevalence and odds ratios (OR) for the diagnostic codes in the cancer population as a whole.
Results: The diagnostic codes with the highest OR were unspecified lump in breast, neoplasm of uncertain behaviour, and abnormal serum enzyme levels. The codes with the highest prevalence were hyperplasia of prostate, other skin changes and abdominal and pelvic pain. The frequency of diagnostic codes and consultations in primary care rose in tandem 50 days before diagnosis for breast and gynaecological cancer, 60 days for malignant melanoma and skin cancer, 80 days for prostate cancer and 100 days for colorectal and lung cancer.
Conclusion: Eighty-seven percent of patients with the most common cancers consulted a general practitioner (GP) a year before their diagnosis. An increase in consultation frequency and presentation of any symptom should raise the GP’s suspicion of cancer.
Key Points
Knowledge about the prevalence of early symptoms and other clinical signs in cancer patients in primary care remains insufficient.
Eighty-seven percent of the patients with the seven most common cancers consulted a general practitioner 12 months prior to cancer diagnosis.
Both the frequency of consultation and the number of symptoms and diseases expressed in diagnostic codes rose in tandem 50–100 days before the cancer diagnosis.
Unless it is caused by a previously known disease, an increased consultation rate for any symptom should result in a swift investigation or referral from primary care to confirm or exclude cancer.
Method: Twenty obese male patients underwent a rehabilitation program including adapted physical activity and respiratory physiotherapy. Patients were randomly assigned to a Specific Motor Control Exercise Group (SG) and a Control Group (CG). SG followed a protocol according to the SMARTERehab concept aimed at improving posture, intra-abdominal pressure, rib cage mobility, and perception of correct muscle activation. CG performed an exercise training protocol to improve aerobic capacity and muscle strength.
Result: After intervention, both groups showed similar changes in body weight, fat, and fat-free mass. Respiratory function indexes improved in SG due to improved proprioception and coordination of the deep lumbar-pelvic muscles.
Conclusion: Our study provides preliminary evidence that breathing, postural control, and spinal stability are intertwined. Positive respiratory effects in obese men can be obtained by prescribing specific motor control exercises of the lumbar-pelvic muscles.
- Implications for rehabilitation
Obese subjects present with decreased pulmonary function and postural changes.
Poor coordination of the lumbar-pelvic muscles affects posture and the synergic activation of the respiratory muscles.
Specific motor control exercises of the lumbar-pelvic musculature can improve respiratory function.
Breathing and postural control are intertwined: positive respiratory effects can be obtained by enhancing motor control of the lumbar-pelvic muscles.
Material and method: Qualitative interviews were used to uncover expectations about a multimodal rehabilitation programme offered at the Pain and Rehabilitations Centre, The University Hospital; Linköping, Sweden. Sixteen women and two men (mean age 37 years; standard deviation 10 years) with chronic benign pain participated. The interviews were analysed using qualitative content analyses.
Results: To participate actively in the multimodal pain rehabilitation programme and to learn adequate coping strategies to improve daily life emerged as a main category. It was based on the following four categories comprising expectations about: participating actively in the programme, interacting with the professionals and fellow patients, cognitive effects of the programme and tools for coping, and explicit effects from the programme.
Conclusions: Many patients expressed expectations which may reflect that the information before the programme had started rehabilitation process at the time point for this study. The results could be applied in rehabilitation programmes by acknowledging expectations to interact with professional team members and fellow patients, by early addressing of positive and negative expectations about the future pain and by incorporating and strengthen expectations of learning to cope with pain.
- Implications for Rehabilitation
Patients' expectations to interact with professional team members and fellow patients by participating actively in the pain rehabilitation programme should be acknowledged in each rehabilitation situation.
Patients expressed both positive and negative expectations about their future pain situation and these expectations should be addressed as early as possible in the rehabilitation screening process.
Patients' expectations of learning to cope with pain should be incorporated and strengthened in multimodal pain rehabilitation programmes.