Socioeconomic Differences in Patient Reported Outcome Measures 3 Months After Stroke: A Nationwide Swedish Register-Based Study.

BACKGROUND: There is a well-known association between low socioeconomic status (SES), poor survival, and clinician-reported outcomes after stroke. We aimed to assess socioeconomic differences in Patient Reported Outcome Measures 3 months after stroke. METHODS: This nationwide cohort study included patients registered with acute stroke in the Swedish Stroke Register 2015-2017. Patient Reported Outcome Measures included activities of daily living (mobility, toileting, and dressing), and poststroke symptoms (low mood, fatigue, pain, and poor general health). Information on SES prestroke was retrieved from Statistics Sweden and defined by a composite measure based on education and income tertiles. Associations between SES and Patient Reported Outcome Measures were analyzed using logistic regression adjusting for confounders (sex and age) and additionally for potential mediators (stroke type, severity, cardiovascular disease risk factors, and living alone). Subgroup analyses were performed for stroke type, men and women, and younger and older patients. RESULTS: The study included 44 511 patients. Of these, 31.1% required assistance with mobility, 18% with toileting, and 22.2% with dressing 3 months after stroke. For poststroke symptoms, 12.3% reported low mood, 39.1% fatigue, and 22.7% pain often/constantly, while 21.4% rated their general health as poor/very poor. Adjusted for confounders, the odds of needing assistance with activities of daily living were highest for patients with low income and primary school education, for example, for mobility, odds ratio was 2.06 (95% CI, 1.89-2.24) compared with patients with high income and university education. For poststroke symptoms, odds of poor outcome were highest for patients with low income and university education (eg, odds ratio, 1.79 [95% CI, 1.49-2.15] for low mood). Adjustments for potential mediators attenuated but did not remove associations. The associations were similar in ischemic and hemorrhagic strokes and more pronounced in men and patients <65 years old. CONCLUSIONS: There are substantial SES-related differences in Patient Reported Outcome Measures poststroke. The more severe outcome associated with low SES is more pronounced in men and in patients of working age.

Physical activity modification following a Transient Ischemic Attack in individuals with diabetes.

BACKGROUND: Individuals with diabetes exhibit a higher risk of cardiovascular disease and mortality compared to healthy individuals. Following a transient ischemic attack (TIA) the risk of stroke and death increase further. Physical activity engagement after a TIA is an effective way of secondary prevention. However, there's a lack of research on how individuals with diabetes modify physical activity levels and how these adjustments impact survival post-TIA. This study aimed to determine the extent to which individuals with diabetes alter their physical activity levels following a TIA and to assess the impact of these changes on mortality. METHODS: This was a nationwide longitudinal study, employing data from national registers in Sweden spanning from 01/01/2003 to 31/12/2019. Data were collected 2 years retro- and prospectively of TIA occurrence, in individuals with diabetes. Individuals were grouped based on decreasing, remaining, or increasing physical activity levels after the TIA. Cox proportional hazards models were fitted to evaluate the adjusted relationship between change in physical activity and all-cause, cardiovascular, and non-cardiovascular mortality. RESULTS: The final study sample consisted of 4.219 individuals (mean age 72.9 years, 59.4% males). Among them, 35.8% decreased, 37.5% kept steady, and 26.8% increased their physical activity after the TIA. A subsequent stroke occurred in 6.7%, 6.4%, and 6.1% of individuals, while death occurred in 6.3%, 7.3%, and 3.7% of individuals, respectively. In adjusted analyses, participants who increased their physical activity had a 45% lower risk for all-cause mortality and a 68% lower risk for cardiovascular mortality, compared to those who decreased their physical activity. CONCLUSIONS: Positive change in physical activity following a ΤΙΑ was associated with a reduced risk of mortality. Increased engagement in physical activity should be promoted after TIA, thereby actively supporting individuals with diabetes in achieving improved health outcomes.

Epidemiology of Spinal Cord Injury in Adults in Sweden, 2016-2020: A Retrospective Registry-Based Study.

STUDY DESIGN: We conducted a retrospective, descriptive register study. OBJECTIVE: The aim of the study was to present the epidemiological and demographic characteristics of the Swedish spinal cord injury (SCI) population. SETTING: Rehabilitation units in Sweden were connected to the National Quality Register for Rehabilitation Medicine (Svenskt Register för Rehabiliteringsmedicin: SveReh). The registry includes data from 26 units around the country. METHODS: Information was extracted from SveReh for patients who underwent rehabilitation for a new onset SCI between January 1, 2016, and December 31, 2020. Data regarding gender, age, aetiology, level of injury, neurogenic bowel and/or bladder dysfunction, complications during the primary rehabilitation, and the need for bi-level positive airway pressure, continuous positive airway pressure, or ventilator were analysed. RESULTS: Mean age at onset was 56 years, and men were overrepresented (66%). Tetraplegia was more common among traumatic SCI (TSCI) than non-traumatic SCI (NTSCI). The incidence was 11.9-14.8 per million for TSCI and 8.9-11.8 per million for NTSCI. At discharge, 8% of patients needed a breathing aid. Of those who were ventilator-dependent at discharge, 75% had a TSCI. Disturbed bowel and bladder functioning was noted in 58% of patients at discharge. The median time spent at the unit was 40 days, but it was approximately 2 weeks longer for those with a TSCI. CONCLUSIONS: Systematic and updated data on the Swedish SCI population show a pattern similar to Scandinavian countries with high age at onset and falls being the main cause of TSCI. The TSCI incidence was lower than in previous studies, and the results for NTSCI were novel.

The Prognostic Test Accuracy of the Short and Standard Forms of the Montreal Cognitive Assessment.

INTRODUCTION: Cognitive impairment is a critical concern in stroke care, and international guidelines recommend early cognitive screening. The aim of this study was to determine the prognostic accuracy of both the short and standard forms of the Montreal Cognitive Assessment (MoCA) in predicting long-term cognitive recovery following a stroke. METHODS: For this study, we used data from the Efficacy of Fluoxetine - a Randomized Controlled Trial in Stroke (EFFECTS) study, which encompassed stroke patients from 35 Swedish centers over the period from 2014 to 2019. Cognitive assessments were initially conducted at 2-15 days post-stroke, with follow-up data gathered at 6 months. We used the MoCA for objective cognitive evaluation. For assessing subjective cognitive impairment, we used the memory and thinking domain of the Stroke Impact Scale. For psychometric evaluation of the short Swedish version of MoCA (s-MoCA-SWE), we used cross tables and binary logistic regression. RESULTS: The study included 1,141 patients (62.2% men; median [interquartile range; IQR] age, 72.3 [13.2] years; median [IQR] stroke severity, 3.0 [3.0]). At baseline, the prevalence of cognitive impairment was 71.7% according to the s-MoCA-SWE (≤12) and 67.0% according to the MoCA (≤25). The s-MoCA-SWE demonstrated a sensitivity of 92.3% for correctly identifying patients with objective cognitive impairment and 81.5% for identifying those with subjective impairments at 6 months. Although the s-MoCA-SWE had higher sensitivity, the MoCA had a more balanced sensitivity and specificity in detecting both subjective and objective cognitive impairments. In both crude and multivariable models, the s-MoCA-SWE was more strongly associated than the MoCA with cognitive impairment at 6 months. CONCLUSIONS: Both the short and standard versions of the MoCA appear to be effective in identifying individuals likely to experience persistent cognitive issues following a stroke. Considering the limited time available in an acute stroke unit, the short-form version may be more practical. Nevertheless, further prospective studies are required to validate these findings.

Prevalence, Trajectory, and Predictors of Poststroke Pain: Retrospective Analysis of Pooled Clinical Trial Data Set.

BACKGROUND: Poststroke pain remains underdiagnosed and inadequately managed. To inform the optimum time to initiate interventions, we examined prevalence, trajectory, and participant factors associated with poststroke pain. METHODS: Eligible studies from the VISTA (Virtual International Stroke Trials Archives) included an assessment of pain. Analyses of individual participant data examined demography, pain, mobility, independence, language, anxiety/depression, and vitality. Pain assessments were standardized to the European Quality of Life Scale (European Quality of Life 5 Dimensions 3 Level) pain domain, describing no, moderate, or extreme pain. We described pain prevalence, associations between participant characteristics, and pain using multivariable models. RESULTS: From 94 studies (n>48 000 individual participant data) in VISTA, 10 (n=10 002 individual participant data) included a pain assessment. Median age was 70.0 years (interquartile range [59.0-77.1]), 5560 (55.6%) were male, baseline stroke severity was National Institutes of Health Stroke Scale score 10 (interquartile range [7-15]). Reports of extreme pain ranged between 3% and 9.5% and were highest beyond 2 years poststroke (31/328 [9.5%]); pain trajectory varied by study. Poorer independence was significantly associated with presence of moderate or extreme pain (5 weeks-3 months odds ratio [OR], 1.5 [95% CI, 1.4-1.6]; 4-6 months OR, 1.7 [95% CI, 1.3-2.1]; >6 months OR, 1.5 [95% CI, 1.2-2.0]), and increased severity of pain (5 weeks-3 months: OR, 1.2 [95% CI, 1.1-1.2]; 4-6 months OR, 1.1 [95% CI, 1.1-1.2]; >6 months, OR, 1.2 [95% CI, 1.1-1.2]), after adjusting for covariates. Anxiety/depression and lower vitality were each associated with pain severity. CONCLUSIONS: Between 3% and 9.5% of participants reported extreme poststroke pain; the presence and severity of pain were independently associated with dependence at each time point. Future studies could determine whether and when interventions may reduce the prevalence and severity of poststroke pain.

Predictors of do-not-attempt-resuscitation decisions in patients with infratentorial or large supratentorial intracerebral hemorrhages and consequences thereafter: a register-based, longitudinal study in Sweden.

OBJECTIVES: Do-not-attempt-resuscitation (DNAR) decisions for patients with infratentorial or large supratentorial intracerebral hemorrhages (ICHs) pose clinical and ethical challenges. We aimed to investigate factors associated with DNAR decisions in patients with infratentorial or large (≥30 mL) supratentorial ICH, and differences in complications, treatment, and mortality. MATERIALS & METHODS: This longitudinal, observational study comprised all patients treated for ICH at three stroke units in Gothenburg, Sweden, between November 2014 and June 2019. Patients were identified in the local stroke register, and additional data were collected from medical records and national registries. Mortality rates were followed 1 year after incident ICHs. Factors associated with DNAR decisions, and one-year mortality were explored. RESULTS: Of 307 included patients, 164 received a DNAR decision. Most (75%) decisions were made within 24 h. DNAR decisions were associated with higher age, pre-stroke dependency, stroke severity, and intraventricular hemorrhage. Patients without DNAR decisions received thrombosis prophylaxis, oral antibiotics, and rehabilitative evaluations more frequently. The one-year survival probability was 0.16 (95% confidence interval [CI] 0.11-0.23) in patients with DNAR decisions, and 0.87 (95% CI 0.81-0.92) in patients without DNAR decision. DNAR decisions, higher age, stroke severity, hematoma volume, and comorbidities were associated with increased one-year mortality. Thrombosis prophylaxis and living alone were associated with a lower hazard. CONCLUSION: The majority of DNAR decisions for patients with infratentorial or large supratentorial ICH were made within 48 h. Higher age, pre-stroke dependency, high stroke severity, and intraventricular hemorrhage predicted receiving a DNAR decision. DNAR decisions were strongly associated with increased short- and long-term mortality.

Research priorities to enhance life for people with spinal cord injury: a Swedish priority setting partnership.

STUDY DESIGN: Mixed-method consensus development project. OBJECTIVE: To identify the top ten research priorities for spinal cord injury (SCI). SETTING: Nationwide in Sweden in 2021-22. METHODS: The PSP process proposed by the James Lind Alliance was used. It comprises two main phases: question identification and priority selection. People living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI were included. RESULTS: In the first phase, 242 respondents provided 431 inputs addressing potentially unanswered questions. Of these, 128 were beyond the scope of this study. The remaining 303 were merged to formulate 57 questions. The literature review found one question answered, so 56 questions proceeded to the prioritisation. In the second phase, the interim prioritisation survey, 276 respondents ranked the 56 questions. The top 24 questions then proceeded to the final prioritisation workshop, at which 23 participants agreed on the top ten priorities. CONCLUSIONS: This paper reveals issues that people living with SCI, relatives of people with SCI as well as health professionals and personal care assistants working with people with SCI find difficult to get answered. The top-priority questions for people living with SCI in Sweden concern specialist SCI care and rehabilitation, followed by a number of questions addressing physical health. Other topics, from the 56 key questions include Mental health, Ageing with SCI, Community support and personal care assistance, and Body functions. This result can guide researchers to design appropriate studies relevant to people with SCI. SPONSORSHIP: The project was funded by the Gothenburg Competence Centre for Spinal Cord Injury and the Swedish Association for Survivors of Accident and Injury (RTP).

A cohort study on longitudinal changes in postural balance during the first year after stroke.

INTRODUCTION: Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences. OBJECTIVE: This study aims to examine longitudinal changes in postural balance during the first year after stroke. METHODS: Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors. RESULTS: A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points. CONCLUSIONS: This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

Cognitive screen and employment long-term after infratentorial stroke.

OBJECTIVES: Motor problems are well-described neurological deficits that occur commonly after an infratentorial ischemic stroke. However, the brain stem and cerebellum are also part of the neural interconnections responsible for cognition, emotions, and behavioral responses. We lack studies on long-term cognitive outcomes and patient employment after an infratentorial stroke. In the present study, we described and compared long-term poststroke cognitive outcomes and employment between patients that experienced infratentorial and supratentorial ischemic strokes. MATERIALS AND METHODS: We included consecutive patients that experienced an acute ischemic stroke at ≤58 years of age. Patients were classified according to the stroke location. At seven years poststroke, surviving participants were assessed for neurological deficits (National Institutes of Health Stroke Scale [NIHSS]), functional outcome (modified Rankin Scale [mRS]), cognitive function Barrow Neurological Institute Screen (BNIS), and employment. RESULTS: Among 141 participants, 25 (18%) had infratentorial and 116 (82%) had supratentorial strokes. At the 7-year poststroke follow-up, there was no significant difference in BNIS total scores; with a median of 43 (IQR 40.5-46) and 41 (IQR 38-46) in the infratentorial and supratentorial groups, respectively. This result indicated that cognitive dysfunction occurred frequently in both groups. Similar employment rates were observed in the infratentorial (48%) and supratentorial (55%) groups. Both groups had a median NIHSS score of 0 and a median mRS score of 2 at the 7-year follow-up. CONCLUSION: Patients who survived an infratentorial or supratentorial ischemic stroke had similar rates of long-term cognitive dysfunction and difficulties in returning and/or remaining at work.

Prehospital recognition of stroke is associated with a lower risk of death.

OBJECTIVE: Among patients assessed by the emergency medical service (EMS) and hospitalized with a final diagnosis of stroke, to describe delays, patient characteristics, actions taken and outcome in relation to the early recognition of stroke by the EMS clinician. METHODS: Patients admitted to any of six stroke units in Region Västra Götaland, Sweden, with a final diagnosis of stroke from 1 January 2013 to 31 December 2015 were included. Data on follow-up were retrieved from the Swedish Stroke Register. RESULTS: In all, 5467 patients were included. Stroke was recognized by the EMS clinician in 4396 cases (80.4%). The mean difference in the time from dialling 112 until arrival at the stroke unit was 556 min shorter when stroke was recognized, while the mean difference in the time from dialling 112 until a preliminary report from a computed tomography (CT) scan was 219 min shorter as compared with the patients in whom stroke was not recognized. After adjustment for age, sex, neurological deficits and coma, a lack of suspicion of stroke on EMS arrival was associated with an increased risk of death during three months of follow-up (odds ratio 1.66; 95% confidence interval 1.19-2.32; p = .003). CONCLUSION: Among patients with a stroke, more than 80% were recognized by the EMS clinician. Early recognition of stroke was associated with a markedly shorter time until arrival at the stroke unit and until the preliminary report of a CT scan. A lack of early stroke recognition was associated with an increased risk of death.

Stroke-related health problems and associated actions identified with the post-stroke checklist among nursing home residents.

BACKGROUND: Little is known about the needs of permanent nursing home residents after a stroke; comprehensive descriptions of needs are rare. The Post-Stroke Checklist facilitates the identification of health problems. The study aimed to use the Post-Stroke Checklist to identify the extent of health problems, and how they were addressed, in nursing home residents that experienced strokes in Sweden. We also investigated the feasibility of the Checklist in a nursing home context. METHODS: This is a cross-sectional explorative study. Twenty nursing homes in two regions of Sweden participated. We included residents that had experienced a stroke within approximately 3 years and the responsible staff members were approached. Questionnaires were completed during face-to-face meetings with staff members (n = 45) knowledgeable about the residents. Data collection included the Post-Stroke Checklist, Barthel Index, modified Rankin Scale, resident and staff characteristics, and a satisfaction-questionnaire completed by staff. RESULTS: At the included nursing homes 1061 residents, 22% (n = 239) had a history of stroke, and 6% (n = 65) had experienced strokes during the last 3.5 years. Forty-nine residents were included (41% men, median age, 86 years, range 59-97). Among the health problems identified with the Checklist, activities of daily living (82%) were most common, and spasticity (41%) and pain (29%) were least common. Residents had extensive care needs, with a median of six health problems per resident. The total number of health problems addressed by previous actions i.e., referrals, as suggested in the Checklist, was 124, when recalled by staff. The median Barthel index score was 35. Lack of follow-up after stroke (e.g., by using a checklist) was reported in 17/20 nursing homes. The staff were satisfied with the Post-Stroke Checklist. CONCLUSIONS: We found that more than 1/5 of residents had experienced a stroke; thus, the Post-Stroke Checklist was a useful tool in nursing homes. Half of the residents had more than six health problems, identified with the Post-Stroke Checklist. Extensive needs, combined with a lack of follow-up, indicated a risk of insufficient care. These findings suggested that nursing home routines could be improved with the Post-Stroke Checklist. Trial registration The project is registered in Research web, project number: 256021.

Organisation of services and systems of care in paediatric spinal cord injury rehabilitation in seven countries: a survey with a descriptive cross-sectional design.

STUDY DESIGN: International multicentre cross-sectional study. OBJECTIVES: To describe the organisation and systems of paediatric spinal cord injury (SCI) rehabilitation services in seven countries and compare them with available recommendations and key features of paediatric SCI. SETTING: Ten SCI rehabilitation units in seven countries admitting children and adolescents with SCI < 18 years of age. METHODS: An online survey reporting data from 2017. Descriptive and qualitative analysis were used to describe the data. RESULTS: The units reported large variations in catchment area, paediatric population and referrals, but similar challenges in discharge policy. Nine of the units were publicly funded. Three units had a paediatric SCI unit. The most frequent causes of traumatic injury were motor vehicle accidents, falls, and sports accidents. Unlike the other units, the Chinese units reported acrobatic dancing as a major cause. Mean length of stay in primary rehabilitation ranged between 18 and 203 days. Seven units offered life-long follow-up. There was a notable variation in staffing between the units; some of the teams were not optimal regarding the interdisciplinary and multiprofessional nature of the field. Eight units followed acknowledged standards and recommendations for specialised paediatric SCI rehabilitation and focused on family-centred care and rehabilitation as a dynamic process adapting to the child and the family. CONCLUSIONS: As anticipated, we found differences in the organisation and administration of rehabilitation services for paediatric SCI in the ten rehabilitation units in seven countries. This might indicate a need for internationally approved, evidence-based guidelines for specialised paediatric SCI rehabilitation.

Twelve-Month Outcomes of the AFFINITY Trial of Fluoxetine for Functional Recovery After Acute Stroke: AFFINITY Trial Steering Committee on Behalf of the AFFINITY Trial Collaboration.

BACKGROUND AND PURPOSE: The AFFINITY trial (Assessment of Fluoxetine in Stroke Recovery) reported that oral fluoxetine 20 mg daily for 6 months after acute stroke did not improve functional outcome and increased the risk of falls, bone fractures, and seizures. After trial medication was ceased at 6 months, survivors were followed to 12 months post-randomization. This preplanned secondary analysis aimed to determine any sustained or delayed effects of fluoxetine at 12 months post-randomization. METHODS: AFFINITY was a randomized, parallel-group, double-blind, placebo-controlled trial in adults (n=1280) with a clinical diagnosis of stroke in the previous 2 to 15 days and persisting neurological deficit who were recruited at 43 hospital stroke units in Australia (n=29), New Zealand (4), and Vietnam (10) between 2013 and 2019. Participants were randomized to oral fluoxetine 20 mg once daily (n=642) or matching placebo (n=638) for 6 months and followed until 12 months after randomization. The primary outcome was function, measured by the modified Rankin Scale, at 6 months. Secondary outcomes for these analyses included measures of the modified Rankin Scale, mood, cognition, overall health status, fatigue, health-related quality of life, and safety at 12 months. RESULTS: Adherence to trial medication was for a mean 167 (SD 48) days and similar between randomized groups. At 12 months, the distribution of modified Rankin Scale categories was similar in the fluoxetine and placebo groups (adjusted common odds ratio, 0.93 [95% CI, 0.76-1.14]; P=0.46). Compared with placebo, patients allocated fluoxetine had fewer recurrent ischemic strokes (14 [2.18%] versus 29 [4.55%]; P=0.02), and no longer had significantly more falls (27 [4.21%] versus 15 [2.35%]; P=0.08), bone fractures (23 [3.58%] versus 11 [1.72%]; P=0.05), or seizures (11 [1.71%] versus 8 [1.25%]; P=0.64) at 12 months. CONCLUSIONS: Fluoxetine 20 mg daily for 6 months after acute stroke had no delayed or sustained effect on functional outcome, falls, bone fractures, or seizures at 12 months poststroke. The lower rate of recurrent ischemic stroke in the fluoxetine group is most likely a chance finding. Registration: URL: http://www.anzctr.org.au/; Unique identifier: ACTRN12611000774921.

Effects of Fluoxetine on Outcomes at 12 Months After Acute Stroke: Results From EFFECTS, a Randomized Controlled Trial.

Background and Purpose: The EFFECTS (Efficacy of Fluoxetine­a Randomised Controlled Trial in Stroke) recently reported that 20 mg fluoxetine once daily for 6 months after acute stroke did not improve functional outcome but reduced depression and increased fractures and hyponatremia at 6 months. The purpose of this predefined secondary analysis was to identify if any effects of fluoxetine were maintained or delayed over 12 months. Methods: EFFECTS was an investigator-led, randomized, placebo-controlled, double-blind, parallel group trial in Sweden that enrolled adult patients with stroke. Patients were randomized to 20 mg oral fluoxetine or matching placebo for 6 months and followed for another 6 months. The primary outcome was functional outcome (modified Rankin Scale), at 6 months. Predefined secondary outcomes for these analyses included the modified Rankin Scale, health status, quality of life, fatigue, mood, and depression at 12 months. Results: One thousand five hundred patients were recruited from 35 centers in Sweden between 2014 and 2019; 750 were allocated fluoxetine and 750 placebo. At 12 months, modified Rankin Scale data were available in 715 (95%) patients allocated fluoxetine and 712 (95%) placebo. The distribution of modified Rankin Scale categories was similar in the 2 groups (adjusted common odds ratio, 0.92 [95% CI, 0.76­1.10]). Patients allocated fluoxetine scored worse on memory with a median value of 89 (interquartile range, 75­100) versus 93 (interquartile range, 82­100); P=0.0021 and communication 93 (interquartile range, 82­100) versus 96 (interquartile range, 86­100); P=0.024 domains of the Stroke Impact Scale compared with placebo. There were no other differences in secondary outcomes. Conclusions: Fluoxetine after acute stroke had no effect on functional outcome at 12 months. Patients allocated fluoxetine scored worse on memory and communication on the Stroke Impact Scale compared with placebo, but this is likely to be due to chance. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02683213.

Recurrent sick leave after COVID-19: investigating the first wave of the pandemic in a comprehensive Swedish registry-based study.

BACKGROUND: Sick-leave due to COVID-19 vary in length and might lead to re-current episodes. The aim was to investigate recurrent sick leave due to COVID-19 during the first wave. METHODS: This is a registry-based cohort study. The study comprises all people with sickness benefit due to COVID-19 in Sweden in March 1-August 31, 2020. Data from the Swedish Social Insurance Agency, the Swedish National Board of Health and Welfare, and Statistics Sweden were merged. RESULTS: Within the follow-up period of 4 months, 11,955 people were subject to sickness benefit due to COVID-19, whereof 242 people (2.0%) took recurrent sick leave due to COVID-19, and of those 136 (56.2%) remained on sick leave at the end of follow-up. People with recurrent sick leave were older, more often women, and more likely to have been on sick leave prior to the COVID-19 pandemic. CONCLUSION: A group of people presented with recurrent sick leave due to COVID-19. For half of them, the second sick leave lasted throughout the follow-up. People with recurrent sick leave differ in several aspects from those with shorter sick leave. To capture long-term sick-leave patterns due to COVID-19, a longer period of follow-up is needed.

Patterns and predictors of sick leave after Covid-19 and long Covid in a national Swedish cohort.

BACKGROUND: The impact of Covid-19 and its long-term consequences is not yet fully understood. Sick leave can be seen as an indicator of health in a working age population, and the present study aimed to investigate sick-leave patterns after Covid-19, and potential factors predicting longer sick leave in hospitalised and non-hospitalised people with Covid-19. METHODS: The present study is a comprehensive national registry-based study in Sweden with a 4-month follow-up. All people who started to receive sickness benefits for Covid-19 during March 1 to August 31, 2020, were included. Predictors of sick leave ≥1 month and long Covid (≥12 weeks) were analysed with logistic regression in the total population and in separate models depending on inpatient care due to Covid-19. RESULTS: A total of 11,955 people started sick leave for Covid-19 within the inclusion period. The median sick leave was 35 days, 13.3% were on sick leave for long Covid, and 9.0% remained on sick leave for the whole follow-up period. There were 2960 people who received inpatient care due to Covid-19, which was the strongest predictor of longer sick leave. Sick leave the year prior to Covid-19 and older age also predicted longer sick leave. No clear pattern of socioeconomic factors was noted. CONCLUSIONS: A substantial number of people are on sick leave due to Covid-19. Sick leave may be protracted, and sick leave for long Covid is quite common. The severity of Covid-19 (needing inpatient care), prior sick leave, and age all seem to predict the likelihood of longer sick leave. However, no socioeconomic factor could clearly predict longer sick leave, indicating the complexity of this condition. The group needing long sick leave after Covid-19 seems to be heterogeneous, indicating a knowledge gap.

Respiratory complications during initial rehabilitation and survival following spinal cord injury in Sweden: a retrospective study.

STUDY DESIGN: Retrospective study. OBJECTIVES: To determine prevalence of respiratory complications in individuals with spinal cord injury (SCI) during the initial rehabilitation at the spinal cord injury unit (SCU) and to describe the subsequent effect on mortality. SETTING: The SCU at the university hospital in Gothenburg, Sweden. METHODS: We reviewed the medical charts of newly injured persons with SCI who were admitted to the SCU between 1/1/2010 and 12/31/2014. Outcome measures were time to death, length of stay, occurrence of respiratory complications, and the use of breathing aids. RESULTS: A total of 136 consecutive individuals were included; 53% with cervical SCI and 20% with lower SCI suffered from one or several respiratory complications during their initial rehabilitation in the SCU. At follow-up, 10/1/2018, 20% of the individuals were deceased. The most common cause of death was related to respiratory insufficiency. The individuals with respiratory complications during the initial rehabilitation in the SCU had particularly shortened survival compared with those without. The relative risk (RR) of dying if the person suffered from any respiratory complications during their initial rehabilitation in the SCU was 2.1 times higher than for those with no respiratory complications (RR, 2.1; 95% CI, 1.1-3.9). CONCLUSIONS: Having respiratory complications at the SCU provides preliminary data to support the claim that respiratory complications predict premature mortality. Early diagnosis and prophylactic measures seem to be necessary to mitigate the adverse consequences of serious respiratory problems.

Associations between upper extremity functioning and kinematics in people with spinal cord injury.

INTRODUCTION: More knowledge of the relationships between kinematic measures and clinical assessments is required to guide clinical decision making and future research. OBJECTIVES: To determine which kinematic variables obtained during a drinking task were associated with clinical assessments of upper extremity functioning in people with spinal cord injury (SCI). METHODS: In total, 25 individuals with chronic cervical (n = 17) or thoracic (n = 8) complete (n = 14) or motor incomplete (n = 11) SCI (mean age 58.4, SD 13.8) were included. Kinematic data, including movement time, smoothness and joint angles was captured with a 5-camera optoelectronic system during a unimanual drinking task. Action Research Arm Test (ARAT), Sollerman Hand Function Test (SHFT) and basic hand classification of the Upper Extremity Data Set (ISCI-Hand) were used as clinical assessments. Multiple regression analysis was used to identify kinematic variables associated with clinical assessments after controlling for potential confounding factors, such as, age, severity of SCI, sensory function, and hand surgery. RESULTS: Movement time, smoothness and movement pattern kinematics including trunk displacement, elbow and wrist joint angles were correlated (p < 0.05) with all three clinical scales while the velocity-related kinematics and inter-joint coordination showed low correlations. Multiple regression analysis revealed that wrist angle combined with movement time or smoothness explained 82% and 77% of the total variance in ARAT and SHFT, respectively. Wrist angle alone explained 59% of the variance in ISCI-Hand. The proprioception of the hand increased the explanatory power in the models of ARAT and SHFT. Associations between kinematics and clinical assessments in the subgroup with cervical SCI were equivalent to the whole group analyses. The number of participants in the subgroup with thoracic SCI was small and only allowed limited analysis. CONCLUSIONS: Wrist angle, movement time, movement smoothness are the most important kinematic variables associated with upper extremity clinical assessments in people with SCI. The results are most valid for individuals with cervical SCI. All three assessments are appropriate for SCI. Further research with larger representative sample of thoracic SCI needed.

Predicting Longitudinal Progression in Functional Mobility After Stroke: A Prospective Cohort Study.

BACKGROUND AND PURPOSE: A majority of people with stroke remain impaired in their functional mobility. The aim of the study was to determine longitudinal changes in functional mobility after stroke. METHODS: The study was of a longitudinal and prospective design. The functional mobility was assessed using the Timed Up-and-Go test on 5 different occasions: 5 days after onset, within 24 hours after discharge, 1 month after discharge, 3 months, and 1 year poststroke. Stroke severity was stratified based on impairments and activity limitations using a baseline cluster analysis. A multilevel model was developed to predict longitudinal progression in functional mobility based on stroke severity. RESULTS: One-hundred-thirty-five patients were included at baseline. Two distinct subgroups (moderate stroke [52%] and mild stroke [48%]) were identified based on impairments and activity limitations using clustering. Ninety-one patients were included in the longitudinal analysis. After controlling for age and cognition, significant improvements in functional mobility were found in the moderate stroke group between baseline and 1 year poststroke (mean difference in Timed Up-and-Go test time, -6.4 s, adjusted P<0.001). Patients with moderate stroke had a maximum rate of improvement in functional mobility during the first 3 months poststroke and then declined significantly at 1 year (12% increase in Timed Up-and-Go test time, adjusted P=0.025). Younger patients had better functional mobility. Although there was also a slight improvement in the mild stroke group, it was not statistically significant. CONCLUSIONS: The recovery of functional mobility differs between mild and moderate stroke. Patients with moderate stroke improved their functional mobility during the first 3 months, after which it decreased significantly. These findings suggest that long-term rehabilitation is desirable to maintain and perhaps increase the gained functional mobility. Older patients and those with moderate impairments and activity limitations have particular needs. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01622205.

Self-perceived postural balance correlates with postural balance and anxiety during the first year after stroke: a part of the randomized controlled GOTVED study.

BACKGROUND: Postural balance is an important rehabilitation outcome, and screening stroke patients for confidence in postural balance during rehabilitation and before hospital discharge is recommended. Early supported discharge could improve postural balance self-confidence. This study aimed to investigate associations between patient self-confidence in postural balance and observer-assessed postural balance and anxiety during the first year after stroke. Whether very early supported discharge (VESD) affects self-confidence in postural balance compared with standard discharge was also evaluated. METHODS: A longitudinal trial for with data extracted from a randomized controlled study of 140 adults with confirmed stroke was conducted. The experimental group received VESD. The control group was discharged according to the standard routine. Postural balance was assessed with Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Falls Efficacy Scale. Anxiety was assessed with the Hospital Anxiety and Depression Scale. Spearman's rank correlation coefficient (rho) was used to test associations between independent variables. The Wilcoxon signed-rank test was used to examine differences over time. A single test, according to Eid, Gollwitzer, and Schmidt, was used to test temporal differences in correlation. RESULTS: The correlation between self-confidence in postural balance and observer-assessed postural balance was 0.62-0.78 in the first year after stroke. The correlation between self-confidence and anxiety was 0.22-0.41 in the first year after stroke. Correlations did not differ by group affiliation at any time point when the postural balance was assessed with BBS. The intervention group had a significantly higher correlation (r = - 0.709) than the control group (r = - 0.416) when postural balance was assessed with the TUG test 1 month after discharge. There were no significant differences in correlations between confidence in postural balance and anxiety between the two groups at any time point. CONCLUSIONS: Patients with mild stroke can accurately assess their confidence in performing daily activities without falling. VESD does not substantially affect the correlation between self-confidence in postural balance and observer assessed postural balance and is safe to use as an alternative to standard discharge. Assessment of self-confidence can provide important information for rehabilitation planning and supporting the physical activity of patients after discharge. TRIAL REGISTRATION: Clinical Trials.gov: NCT01622205 . Registered 19 June 2012 (retrospectively registered).