Physical characteristics and upper-limb treatment with botulinum neurotoxin A in children with cerebral palsy: A population-based study.

AIM: To describe the use of upper-limb botulinum neurotoxin A (BoNT-A) treatment in a population-based sample of children with cerebral palsy (CP), by investigating whether factors may be related to a first upper-limb BoNT-A treatment and whether passive range of motion (ROM) is related to a first BoNT-A treatment after adjustment for confounders. METHOD: Data from five regions in Sweden, in the national registry and follow-up programme for CP (CPUP), were collected for children with spastic or dyskinetic CP assessed between 2000 and 2017. CP subtypes, functional classification levels, and traffic-light-based passive ROM categories were investigated. Data were analysed with logistic regression (odds ratios). RESULTS: Of a total of 496 children (317 males, 179 females; median 2 years, interquartile range 1-5 years, range 1-15 years at first measurement occasion), 22% (n = 108) had received upper-limb BoNT-A treatment, 45% of whom by 1 to 3 years of age. Those classified in Manual Ability Classification System levels IV and V showed the highest crude odds ratio for a first upper-limb BoNT-A treatment. Children with full passive ROM with tightness at the end of the movement range were most likely to receive an upper-limb BoNT-A treatment, also after adjustment for confounders. Thumb and forearm muscles were the most targeted at the first upper-limb BoNT-A treatment. INTERPRETATION: Full passive ROM with tightness at the end of the movement range increases the likelihood of a first upper-limb BoNT-A treatment. This new traffic-light category is an aspect to consider in the dialogue about upper-limb BoNT-A. WHAT THIS PAPER ADDS: Among children receiving upper-limb botulinum neurotoxin A (BoNT-A), 45% had their first treatment before the age of 4 years. Thumb and forearm muscles were the most treated with BoNT-A, finger flexor muscles the least. Full passive range of motion with tightness was related to first upper-limb BoNT-A treatment.

Test-retest reliability of the twenty-five-hole peg test in patients who had a stroke.

OBJECTIVES: Weaknesses of the nine-hole peg test include high floor effects and a result that might be difficult to interpret. In the twenty-five-hole peg test (TFHPT), the larger number of available pegs allows for the straightforward counting of the number of pegs inserted as the result. The TFHPT provides a comprehensible result and low floor effects. The objective was to assess the test-retest reliability of the TFHPT when testing persons with stroke. A particular focus was placed on the absolute reliability, as quantified by the smallest real difference (SRD). Complementary aims were to investigate possible implications for how the TFHPT should be used and for how the SRD of the TFHPT performance should be expressed. DESIGN: This study employed a test-retest design including three trials. The pause between trials was approximately 10-120 s. PARTICIPANTS, SETTING AND OUTCOME MEASURE: Thirty-one participants who had suffered a stroke were recruited from a group designated for constraint-induced movement therapy at outpatient clinics. The TFHPT result was expressed as the number of pegs inserted. METHODS: Absolute reliability was quantified by the SRD, including random and systematic error for a single trial, SRD2.1, and for an average of three trials, SRD2.3. For the SRD measures, the corresponding SRD percentage (SRD%) measure was also reported. RESULTS: The differences in the number of pegs necessary to detect a change in the TFHPT for SRD2.1 and SRD2.3 were 4.0 and 2.3, respectively. The corresponding SRD% values for SRD2.1 and SRD2.3 were 36.5% and 21.3%, respectively. CONCLUSIONS: The smallest change that can be detected in the TFHPT should be just above two pegs for a test procedure including an average of three trials. The use of an average of three trials compared with a single trial substantially reduces the measurement error. TRIAL REGISTRATION NUMBER: ISRCTN registry, reference number ISRCTN24868616.

Upper-limb contracture development in children with cerebral palsy: a population-based study.

AIM: The aim of this study was to investigate the longitudinal development of passive range of motion (ROM) in the upper limbs in a population-based sample of children with cerebral palsy (CP), and to investigate which children are more likely to develop contractures related to functional level, CP subtype, and age. METHOD: Registry data of annual passive ROM measurements of the upper limbs from 771 children with CP (417 males, 354 females; mean age 11y 8mo, [SD 5mo] range 1-18y) were analysed. Mixed models were used to investigate at what age decreased passive ROM occurs. Odds ratios were calculated to compare risks and logistic regression analysis was used to predict contracture development. RESULTS: Thirty-four per cent of the children had developed contractures. Among these children, decreased passive ROM was significant at a mean age of 4 years for wrist extension and 7 years for shoulder flexion, elbow extension, and supination. Children at Manual Ability Classification System (MACS) level V had a 17-times greater risk of contractures than children at MACS level I. INTERPRETATION: One-third of the children in the total population developed upper-limb contractures while passive ROM decreased with age. MACS level was the strongest predictor of contracture development. WHAT THIS PAPER ADDS: In a population-based sample of 771 children with cerebral palsy, 34% developed an upper-limb contracture. Contracture development started at preschool age. The first affected movements were wrist extension and supination. Passive range of motion decreased with age. High Manual Ability Classification System level was the most important predictor of contractures.

Educational differences in psychological distress? Results from a population-based sample of men and women in Sweden in 2012.

BACKGROUND: Mental health problems are more frequent in socially disadvantaged groups, but the results vary between different studies, different populations and different measures of mental health. This paper investigated the association between educational level, economic difficulties and psychological distress in men and women in Sweden. METHODS: The study population included 24 510 respondents aged 25-74 years who responded to a survey questionnaire in Mid-Sweden in 2012 (response rate 53%). Psychological distress was measured with the 12-item version of the General Health Questionnaire, and multivariate logistic regression models were used in statistical analyses, adjusting for age, employment status and social support. RESULTS: The prevalence of psychological distress was higher in women (16.4%) than in men (11.3%; p<0.001). Persons with low and medium educational level had a lower risk of psychological distress than persons with high educational level after adjustment for confounders. Economic difficulties had a strong association with psychological distress (OR 2.80 (95% CI 2.39 to 3.27) and OR 2.40 (95% CI 2.12 to 3.71) in men and women, respectively) after adjustment for confounders. CONCLUSION: We found a strong association between economic difficulties and psychological distress in this study, but no inverse association between educational level and psychological distress. On the contrary, persons with high education had more psychological distress than persons with low and medium education when age, employment status and social support were taken into account. The findings were similar in men and women.

Economic stress and condescending treatment in childhood and adult self-rated health: results from a population study in Sweden.

BACKGROUND: Even today, 12% of the children in Sweden live in poverty and many children are exposed to adverse experiences, such as being bullied, which may have long-term consequences on public health. This study examined the associations between economic stress and condescending treatment in childhood and self-rated health (SRH) in adulthood. METHODS: The study is based on 26,706 persons who responded to a postal survey questionnaire sent to a random sample of men and women aged 25-84 years in 2012 (response rate 53%). The associations between childhood circumstances and adult SRH were analysed by logistic regression, adjusting for sex, age, economic stress in adulthood, condescending treatment in adulthood, socioeconomic status and several other known material, behavioural and psychosocial risk factors. RESULTS: In total, 39% of both men and women reported economic stress in their family during childhood. 36% of the men and 41% of the women indicated that they had been treated in a condescending manner, e.g. in school or at home, during childhood. Both economic stress in childhood and condescending treatment in childhood were strongly associated with adult SRH. The associations attenuated, but were still statistically significant after adjustment for adulthood circumstances and other risk factors. CONCLUSION: Economic stress in childhood and condescending treatment in childhood were associated with SRH in adulthood, both independently and through adulthood circumstances. The results underline the importance of taking into account both material and psychosocial circumstances over the whole life course when developing public health measures.

Obesity continues to increase in the majority of the population in mid-Sweden-a 12-year follow-up.

BACKGROUND: The aim was to investigate trends in the prevalence of obesity by age and level of education in the general population in mid-Sweden from year 2000 to 2012. METHODS: A postal questionnaire was sent to a random population sample aged 25-74 years in years 2000, 2004, 2008 and 2012. The overall response rates were 67%, 65%, 60% and 53%, respectively, and the study included 29 017, 27 385, 25 910 and 24 152 respondents, respectively. Obesity (BMI ≥ 30 kg/m(2)) was based on self-reported weight and height. RESULTS: The age-standardized prevalence of obesity increased from 13% to 17% in women and from 12% to 17% in men between 2000 and 2012. Obesity increased in all age groups from 2000 to 2008 and continued to increase among the middle aged (45-64 years) between 2008 and 2012. The socioeconomic gradient in obesity changed during the study period since the absolute increase in obesity was steepest at the middle educational level. In 2012, the prevalence of obesity was almost twice as high at both middle and low educational levels compared with high educational level. The 'true' prevalence of adult obesity, corrected for self-reported weight and height, was around 20% in 2012 for both men and women. CONCLUSION: In the majority, among the middle-aged and those with secondary education, the prevalence of obesity continued to increase even between 2008 and 2012.

Exploring trends in and determinants of educational inequalities in self-rated health.

AIMS: Educational inequalities in self-rated health (SRH) in European welfare countries are documented, but recent trends in these inequalities are less well understood. We examined educational inequalities in SRH in different age groups, and the contribution of selected material, behavioural and psychosocial determinants from 2000 to 2008. METHODS: Data were derived from cross-sectional surveys conducted in 2000, 2004 and 2008 including 37,478, 34,876 and 32,982 respondents, respectively, aged 25-75 in mid-Sweden. Inequalities were analysed by age-standardized and age-stratified rate ratios of poor SRH and age-standardized prevalence of determinants, and contribution of determinants by age-adjusted logistic regression. RESULTS: Relative educational inequalities in SRH increased among women from 2000 (rate ratio (RR) 1.70, 95% CI 1.55-1.85) to 2008 (RR 2.07, 95% CI 1.90-2.26), but were unchanged among men (RR 1.91-2.01). The increase among women was mainly due to growing inequalities in the age group 25-34 years. In 2008, significant age differences emerged with larger inequalities in the youngest compared with the oldest age group in both genders. All determinants were more prevalent in low educational groups; the most prominent were lack of a financial buffer, smoking and low optimism. Educational differences were unchanged over the years for most determinants. In all three surveys, examined determinants together explained a substantial part of the educational inequalities in SRH. CONCLUSIONS: Increased relative educational health inequalities among women, and persisting inequalities among men, were paralleled by unchanged, large differences in material/structural, behavioural and psychosocial factors. Interventions to reduce these inequalities need to focus on early mid-life.

Domestic work and self-rated health among women and men aged 25-64 years: results from a population-based survey in Sweden.

AIMS: This study investigated the association between domestic work and self-rated health among women and men in the general population. METHODS: The study is based on women (N = 12,910) and men (N = 9784) aged 25-64 years, who responded to a survey questionnaire in 2008 (response rate 56%). Logistic regression models were used to assess the association adjusting for age, educational level, employment status, family status and longstanding illness. Population attributable risks (PAR) were calculated to assess the contribution of domestic work to the prevalence of suboptimal self-rated health. RESULTS: More women (29%) than men (12%) spent more than 20 hours per week in domestic work. Women also experienced domestic work more often as burdensome. Disability pensioners and single mothers reported highest levels of burdensome domestic work. There was a strong independent association between burdensome domestic work and suboptimal self-rated health both in women and men. The PAR for burdensome domestic work was 21% in women and 12% in men and comparable to other major risk factors. CONCLUSIONS: The results suggest that domestic work should not be omitted when considering factors that affect self-rated health in the general population.

Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement.

OBJECTIVE: Although the working alliance as been found to be a robust predictor of psychotherapy outcome, critics have questioned the causal status of this effect. Specifically, the effect of the alliance may be confounded with the effect of prior symptom improvement. The objective of the present study was to test this possibility. METHOD: A large dataset from primary care psychotherapy was used to study relationships between alliance and outcome using piecewise multilevel path analysis. RESULTS: Initial symptom level and symptom change up to session three predicted the alliance at session three. Working alliance significantly predicted symptom change rate from session three to termination, even while controlling for several possible confounds. CONCLUSIONS: The alliance predicts outcome over and above the effect of prior symptom improvement, supporting a reciprocal influence model of the relationship between alliance and symptom change.

Therapeutic alliance predicts symptomatic improvement session by session.

The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation-Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory-Short form revised (Hatcher & Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy.

Can financial insecurity and condescending treatment explain the higher prevalence of poor self-rated health in women than in men? A population-based cross-sectional study in Sweden.

INTRODUCTION: Women have in general poorer self-rated health than men. Both material and psychosocial conditions have been found to be associated with self-rated health. We investigated whether two such factors, financial insecurity and condescending treatment, could explain the difference in self-rated health between women and men. METHODS: The association between the two factors and self-rated health was investigated in a population-based sample of 35,018 respondents. The data were obtained using a postal survey questionnaire sent to a random sample of men and women aged 18-75 years in 2008. The area covers 55 municipalities in central Sweden and the overall response rate was 59%. Multinomial odds ratios for poor self-rated health were calculated adjusting for age, educational level and longstanding illness and in the final model also for financial insecurity and condescending treatment. RESULTS: The prevalence of poor self-rated health was 7.4% among women and 6.0% among men. Women reported more often financial insecurity and condescending treatment than men did. The odds ratio for poor self-rated health in relation to good self-rated health was 1.29 (95% CI: 1.17-1.42) for women compared to men when adjusted for age, educational level and longstanding illness. The association became, however, statistically non-significant when adjusted for financial insecurity and condescending treatment. CONCLUSION: The present findings suggest that women would have as good self-rated health as men if they had similar financial security as men and were not treated in a condescending manner to a larger extent than men. Longitudinal studies are, however, required to confirm this conclusion.

Aspects of health, physical/leisure activities, work and socio-demographics associated with pet ownership in Sweden.

AIMS: The aim of the work presented here was to explore differences between pet owners and non-pet-owners concerning aspects of health, physical/leisure activities, work and socio-demographics. METHODS: The study was based on nationally representative data from the Swedish population (n = 43,589). Associations between pet ownership and background variables were investigated using logistic regression analysis. RESULTS: A total of 39,995 respondents were included in the analysis (non-pet-owners = 25,006; pet owners = 14,989). Pet ownership was associated with both positive and negative aspects of health, physical/leisure activities and socio-demographics. Pet owners had better general health but suffered more from mental health problems than non-pet-owners. Their leisure activities involved a greater interest in nature life and/or gardening than those of non-pet-owners. The logistic regression analysis showed that people who were self-employed, in the age range 35 to 49, of female sex, and suffering from pain in the head, neck and shoulders were more likely to own a pet than others. People physically active at a level sufficient to have a positive effect on their health more often owned a pet than people who were less active. CONCLUSIONS: Pet owners differ from non-pet-owners in aspects of socio-demographics, health, physical/leisure activities and work situation. This study, based on a general regional population in Sweden, showed differences of both a positive and a negative kind between non-pet-owners and pet owners concerning aspects of health, physical and leisure activities, and work situation.