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This article was downloaded by: [Marklund, Ingela]<br />
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<strong>Advances</strong> <strong>in</strong> <strong>Physiotherapy</strong><br />
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<strong>“I</strong> <strong>got</strong> <strong>knowledge</strong> <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an easier life”:<br />
Stroke patients' experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT<br />
Ingela Marklund abc ; Maria Klässbo d ; Birgitta Hedel<strong>in</strong> ef<br />
a Department <strong>of</strong> <strong>Physiotherapy</strong>, Torsby Hospital, Sweden b Research Centre for Primary Care,<br />
Värml<strong>and</strong> County Council, Karlstad, Sweden c Department <strong>of</strong> Community Medic<strong>in</strong>e <strong>and</strong><br />
Rehabilitation, Umeå University, Sweden d Centre for Cl<strong>in</strong>ical Research, Värml<strong>and</strong> County Council,<br />
Karlstad, Sweden e Department <strong>of</strong> Nurs<strong>in</strong>g, Gjövik University College, Gjövik, Norway f Department<br />
<strong>of</strong> Nurs<strong>in</strong>g Science, Karlstad University, Karlstad, Sweden<br />
First published on: 04 August 2009<br />
To cite this Article Marklund, Ingela, Klässbo, Maria <strong>and</strong> Hedel<strong>in</strong>, Birgitta(2009) '<strong>“I</strong> <strong>got</strong> <strong>knowledge</strong> <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong><br />
prospects for lead<strong>in</strong>g an easier life”: Stroke patients' experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT', <strong>Advances</strong> <strong>in</strong><br />
<strong>Physiotherapy</strong>,, First published on: 04 August 2009 (iFirst)<br />
To l<strong>in</strong>k to this Article: DOI: 10.1080/14038190903141048<br />
URL: http://dx.doi.org/10.1080/14038190903141048<br />
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<strong>Advances</strong> <strong>in</strong> <strong>Physiotherapy</strong><br />
2009, 1 8, iFirst article<br />
ORIGINAL ARTICLE<br />
‘‘I <strong>got</strong> <strong>knowledge</strong> <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an easier<br />
life’’: Stroke patients’ experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT<br />
INGELA MARKLUND 1 , MARIA KLÄSSBO 2 & BIRGITTA HEDELIN 3<br />
1 Department <strong>of</strong> <strong>Physiotherapy</strong>, Torsby Hospital, Sweden, Research Centre for Primary Care, Värml<strong>and</strong> County Council,<br />
Karlstad, Sweden <strong>and</strong> Department <strong>of</strong> Community Medic<strong>in</strong>e <strong>and</strong> Rehabilitation, Umea˚ University, Sweden, 2 Centre for<br />
Cl<strong>in</strong>ical Research, Värml<strong>and</strong> County Council, Karlstad, Sweden, 3 Department <strong>of</strong> Nurs<strong>in</strong>g, Gjövik University College, Gjövik,<br />
Norway <strong>and</strong> Department <strong>of</strong> Nurs<strong>in</strong>g Science, Karlstad University, Karlstad, Sweden<br />
Abstract<br />
Rehabilitation after stroke has changed <strong>and</strong> more studies with <strong>in</strong>tensive therapy have been conducted. When a new<br />
method here lower-limb constra<strong>in</strong>t-<strong>in</strong>duced movement therapy (CIMT) is <strong>in</strong>troduced, it is important to <strong>in</strong>vestigate<br />
participants’ own experience <strong>of</strong> the therapy. The present purpose was accord<strong>in</strong>gly to describe stroke patients’ experience <strong>of</strong><br />
tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT. Qualitative <strong>in</strong>terviews with seven stroke patients who had participated <strong>in</strong> lower-limb CIMT<br />
were conducted. The <strong>in</strong>terviews were transcribed verbatim <strong>and</strong> analysed with qualitative content analysis. One theme,<br />
<strong>knowledge</strong> <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an easier life, emerged. Two ma<strong>in</strong> categories were found: the therapy <strong>and</strong> me <strong>and</strong><br />
<strong>my</strong> body, with four <strong>and</strong> three categories respectively. The therapy comprised the <strong>in</strong>formants’ experience <strong>of</strong> preparation for<br />
CIMT, the actual <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g <strong>and</strong> its effects, <strong>and</strong> their views on the physiotherapists <strong>in</strong>volved. Me <strong>and</strong> <strong>my</strong> body<br />
comprised the <strong>in</strong>formants’ reflections on their own significance for the therapy, how the reflections had affected them <strong>and</strong><br />
what <strong>in</strong>sight <strong>in</strong>to their condition CIMT had given. The <strong>in</strong>formants reported that CIMT for the lower extremity gave them<br />
<strong>knowledge</strong> <strong>of</strong> their body <strong>and</strong> their prospects for lead<strong>in</strong>g an easier life. The <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g <strong>in</strong>stilled hope, s<strong>in</strong>ce the<br />
functional improvements showed the possibilities <strong>of</strong> improvements, <strong>in</strong>creas<strong>in</strong>g the respondents’ <strong>in</strong>dependence <strong>and</strong> selfesteem.<br />
Even though the <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g is tough, it was experienced as entirely necessary.<br />
Key words: Stroke, physiotherapy, Constra<strong>in</strong>t-<strong>in</strong>duced movement therapy, qualitative content analysis<br />
Introduction<br />
Stroke is among the most common causes <strong>of</strong> <strong>in</strong>validity<br />
<strong>in</strong> Sweden. With lengthen<strong>in</strong>g life expectancy <strong>and</strong><br />
survival after earlier stroke, the prevalence is <strong>in</strong>creas<strong>in</strong>g<br />
(1). The situation is <strong>of</strong> great importance <strong>in</strong> the<br />
community <strong>and</strong> similar <strong>in</strong> many western countries.<br />
Constra<strong>in</strong>t-<strong>in</strong>duced movement therapy (CIMT) is<br />
an approach <strong>in</strong> stroke rehabilitation, developed by<br />
Taub & Wolf (2). It targets motor recovery by<br />
limit<strong>in</strong>g the use <strong>of</strong> the unaffected limb <strong>and</strong> promot<strong>in</strong>g<br />
normal co-ord<strong>in</strong>ated movement <strong>of</strong> the affected<br />
limb through massed practice. The therapy <strong>in</strong>volves<br />
plac<strong>in</strong>g the unaffected upper extremity <strong>in</strong> a sl<strong>in</strong>g <strong>and</strong><br />
target<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g <strong>of</strong> the affected upper extremity 6 h/<br />
day for 2 weeks (2 4). Studies show that CIMT can<br />
improve activities <strong>of</strong> daily liv<strong>in</strong>g (ADL), <strong>and</strong> that<br />
these improvements persist at follow-up 2 years after<br />
completed CIMT. The bra<strong>in</strong>’s plastic ability has<br />
been <strong>in</strong>vestigated <strong>in</strong> connection with <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g<br />
<strong>and</strong> is considered to play a part <strong>in</strong> expla<strong>in</strong><strong>in</strong>g the<br />
effect <strong>of</strong> CIMT (2,5 7).<br />
Formerly, when a person with stroke has arrived at<br />
a plateau <strong>of</strong> functional recovery, it was hard to<br />
achieve further improvements. However, Page et al.<br />
(8) considered that this should be reassessed.<br />
Instead, rehabilitation <strong>in</strong>terventions should be reviewed<br />
regard<strong>in</strong>g their <strong>in</strong>tensity, <strong>and</strong> tra<strong>in</strong><strong>in</strong>g should<br />
be more varied to overcome learned movement<br />
patterns. Kwakkel et al. (9) showed <strong>in</strong> their review<br />
article that <strong>in</strong>tensity, def<strong>in</strong>ed <strong>in</strong> time, is significant.<br />
Higher therapy <strong>in</strong>tensity gave better results <strong>in</strong> ADL<br />
<strong>and</strong> <strong>in</strong> neuromuscular function.<br />
How people with stroke experience CIMT is still<br />
unknown. In one article, post-stroke patients <strong>and</strong><br />
Correspondence: Ingela Marklund, Department <strong>of</strong> <strong>Physiotherapy</strong>, Torsby Hospital, Box 502, 685 29 Torsby, Sweden. E-mail: <strong>in</strong>gela.marklund@liv.se<br />
(Received 18 February 2009; accepted 23 June 2009)<br />
ISSN 1403-8196 pr<strong>in</strong>t/ISSN 1651-1948 onl<strong>in</strong>e # 2009 Informa UK Ltd.<br />
DOI: 10.1080/14038190903141048
Downloaded By: [Marklund, Ingela] At: 07:14 27 November 2009<br />
2 I. Marklund et al.<br />
personnel were both asked their views on the<br />
method employed, but none <strong>of</strong> them have had<br />
personal experience <strong>of</strong> CIMT (10). On the other<br />
h<strong>and</strong>, some articles describe how it is to live with<br />
stroke <strong>and</strong> their experiences when physiotherapy/<br />
rehabilitation <strong>in</strong>terventions are concluded (11 13).<br />
People with stroke <strong>of</strong>ten have high goals <strong>and</strong><br />
expectations regard<strong>in</strong>g rehabilitation. Some consider<br />
that there cannot be too much tra<strong>in</strong><strong>in</strong>g <strong>and</strong> express<br />
their disappo<strong>in</strong>tment at not gett<strong>in</strong>g enough (13).<br />
One <strong>in</strong>terview study also shows that younger persons<br />
with stroke become frustrated that the rehabilitation<br />
is not adapted to their needs (14).<br />
Few published articles discuss CIMT for the<br />
lower extremity. The effect <strong>of</strong> CIMT for the lower<br />
extremity appears to resemble that for the upper<br />
extremity (15 17). Regard<strong>in</strong>g CIMT for the lower<br />
extremity, the leg cannot be fixed <strong>in</strong> a sl<strong>in</strong>g. The use<br />
<strong>of</strong> the unaffected limb can be restricted with a<br />
whole-leg orthosis that prevents knee flexion<br />
(16,17). The lower-limb CIMT (16,18) consists <strong>of</strong><br />
tra<strong>in</strong><strong>in</strong>g 6 h/day for 2 weeks. Each tra<strong>in</strong><strong>in</strong>g session<br />
last for an hour <strong>and</strong> the patients are active at least<br />
40 m<strong>in</strong> <strong>of</strong> every hour. The patients are <strong>in</strong>structed to<br />
perform as near their maximum as they could <strong>in</strong><br />
every session. To <strong>in</strong>crease the use <strong>of</strong> the affected leg,<br />
daily tra<strong>in</strong><strong>in</strong>g <strong>in</strong>cluded <strong>in</strong> vary<strong>in</strong>g order cycl<strong>in</strong>g,<br />
pool tra<strong>in</strong><strong>in</strong>g, functional strength tra<strong>in</strong><strong>in</strong>g <strong>in</strong> different<br />
start position (sitt<strong>in</strong>g down, st<strong>and</strong> up <strong>and</strong> lay<br />
down), load exercises with weight transfer, st<strong>and</strong><strong>in</strong>g,<br />
weight-bear<strong>in</strong>g <strong>in</strong> different directions, stair tra<strong>in</strong><strong>in</strong>g<br />
without use <strong>of</strong> banister, <strong>in</strong>door walk<strong>in</strong>g, outdoor<br />
walk<strong>in</strong>g on uneven surfaces <strong>and</strong> passive (jo<strong>in</strong>t)<br />
mobility tra<strong>in</strong><strong>in</strong>g.<br />
When a new method is <strong>in</strong>troduced, it is important<br />
to <strong>in</strong>vestigate participants’ own experience <strong>of</strong> the<br />
therapy. The present purpose was to describe what<br />
experience people with stroke have <strong>of</strong> CIMT for the<br />
lower extremity.<br />
Methods<br />
The study has an <strong>in</strong>ductive qualitative approach<br />
based on the assumption that people’s experience<br />
constitutes significant <strong>knowledge</strong>. The aim <strong>of</strong> such<br />
approaches is to obta<strong>in</strong> rich descriptions <strong>of</strong> the<br />
phenomenon under study. For this reason, openness<br />
to the <strong>in</strong>formants’ experience is important (19,20).<br />
Informants <strong>and</strong> data collection<br />
The <strong>in</strong>formants were recruited from a rehabilitation<br />
department <strong>in</strong> Sweden where CIMT for the lower<br />
extremities is conducted. CIMT for the lower<br />
extremity at this department consist <strong>of</strong> <strong>in</strong>tensive<br />
tra<strong>in</strong><strong>in</strong>g 6 h/day for 2 weeks, with the unaffected leg<br />
restricted with a whole-leg orthosis. Strength tra<strong>in</strong><strong>in</strong>g,<br />
weight-bear<strong>in</strong>g <strong>in</strong> different directions, <strong>in</strong>door/<br />
outdoor walk<strong>in</strong>g, stair tra<strong>in</strong><strong>in</strong>g <strong>and</strong> stretch<strong>in</strong>g <strong>of</strong> stiff<br />
muscles are <strong>in</strong>cluded <strong>in</strong> the programme. The <strong>in</strong>clusion<br />
criteria for participat<strong>in</strong>g <strong>in</strong> lower-limb CIMT<br />
at this cl<strong>in</strong>ic were: the patients have to be able to<br />
walk outdoors with or without walk<strong>in</strong>g aid, motivated<br />
<strong>and</strong> prepared for the hard tra<strong>in</strong><strong>in</strong>g; score over<br />
23/30 po<strong>in</strong>ts <strong>in</strong> the M<strong>in</strong>i-Mental State Exam<strong>in</strong>ation<br />
(MMSE) <strong>and</strong> not more than 4 s difference between<br />
results from Timed Up <strong>and</strong> Go (TUG) with <strong>and</strong><br />
without a glass <strong>of</strong> water were also required. At this<br />
rehabilitation department, 16 people had participated<br />
<strong>in</strong> CIMT for the lower extremity when this<br />
study started.<br />
Inclusion criteria <strong>in</strong> this study referred to people<br />
with stroke who: 1) had completed CIMT for the<br />
lower extremity, 2) were resident <strong>in</strong> Sweden, 3) were<br />
able to express themselves <strong>in</strong> Swedish <strong>and</strong> 4) were not<br />
suffer<strong>in</strong>g from other serious diseases. Exclusion<br />
criteria were patients known or treated by the authors.<br />
Twelve people met the <strong>in</strong>clusion criteria <strong>and</strong><br />
received oral <strong>and</strong> written <strong>in</strong>formation from the<br />
treat<strong>in</strong>g physiotherapist <strong>and</strong> a reply-paid letter to<br />
notify their <strong>in</strong>terest to participate. Seven <strong>in</strong>formants,<br />
four men <strong>and</strong> three women, expressed <strong>in</strong>terest <strong>and</strong><br />
gave their <strong>in</strong>formed consent (Table I). All had<br />
participated <strong>in</strong> traditional care for patients with<br />
stroke, <strong>in</strong> Sweden, before CIMT for the lower<br />
extremity.<br />
Data was collected dur<strong>in</strong>g October <strong>and</strong> November<br />
2006 us<strong>in</strong>g qualitative <strong>in</strong>terviews <strong>in</strong> the <strong>in</strong>formant’s<br />
homes, except for one <strong>in</strong>formant where the <strong>in</strong>terview<br />
was held at the rehabilitation department. An <strong>in</strong>terview<br />
guide was used, conta<strong>in</strong><strong>in</strong>g the overall prompt,<br />
‘‘Describe how you experienced the <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g’’.<br />
Follow-up questions were then asked for more<br />
depth <strong>and</strong> clarification. The <strong>in</strong>terviews took 35<br />
60 m<strong>in</strong>, were recorded <strong>and</strong> then transcribed verbatim<br />
by the author (IM) (one <strong>in</strong>terview) <strong>and</strong> by a<br />
medical secretary (six <strong>in</strong>terviews).<br />
Table I. Characteristics <strong>of</strong> the <strong>in</strong>formants <strong>in</strong>cluded <strong>in</strong> the study.<br />
Informant Sex<br />
Age<br />
(years)<br />
Affected<br />
side<br />
(right/left)<br />
Time s<strong>in</strong>ce<br />
stroke<br />
event<br />
(years)<br />
1 Man 48 Left 4<br />
2 Woman 57 Right 11<br />
3 Man 65 Right 1<br />
4 Man 49 Left 6<br />
5 Woman 74 Left 4<br />
6 Woman 35 Right 16<br />
7 Man 58 Left 3
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The author (IM) has experience <strong>of</strong> work<strong>in</strong>g, for<br />
several years, as a physiotherapist with people with<br />
neurological diseases <strong>and</strong> has conducted CIMT both<br />
for upper <strong>and</strong> lower extremity <strong>in</strong> persons with stroke<br />
before the study started. The other authors have<br />
m<strong>in</strong>or or none experience <strong>of</strong> work<strong>in</strong>g with persons<br />
with stroke or CIMT but have used qualitative<br />
<strong>in</strong>terviews for research purposes.<br />
Data analysis<br />
The data material was processed us<strong>in</strong>g qualitative<br />
content analysis (21,22). The authors met <strong>and</strong><br />
analysed three <strong>in</strong>terviews jo<strong>in</strong>tly, after which one <strong>of</strong><br />
them (IM) analysed the rema<strong>in</strong><strong>in</strong>g four <strong>in</strong> the same<br />
way with cont<strong>in</strong>uous feedback from the other<br />
authors throughout the whole process. First, all<br />
data was read by all the authors to obta<strong>in</strong> a sense<br />
<strong>of</strong> the whole. Then mean<strong>in</strong>gful units were extracted<br />
<strong>and</strong> condensed to capture key thoughts or concepts.<br />
These mean<strong>in</strong>gful units were labelled <strong>and</strong> sorted by<br />
similarities <strong>and</strong> differences. The latent content, i.e.<br />
the implicit mean<strong>in</strong>g <strong>of</strong> the text, <strong>and</strong> the manifest<br />
content, what was explicit expressed, were analysed.<br />
Ma<strong>in</strong> categories <strong>and</strong> categories were created from<br />
the manifest content <strong>of</strong> the material <strong>and</strong> were<br />
exhaustive <strong>and</strong> mutually exclusive (21). F<strong>in</strong>ally,<br />
one theme was formulated that corresponded to<br />
the latent content <strong>of</strong> the texts (22).<br />
Ethical considerations<br />
The regional Board <strong>of</strong> Research Ethics at Uppsala<br />
University, Sweden, (Dnr2006/039) approved the<br />
study.<br />
Results<br />
When analys<strong>in</strong>g the data one theme emerged <strong>knowledge</strong><br />
<strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an easier life.<br />
This theme constituted the latent content <strong>of</strong><br />
the material. Two ma<strong>in</strong> categories the manifest<br />
content were found: the therapy <strong>and</strong> me <strong>and</strong> <strong>my</strong><br />
body, with four <strong>and</strong> three categories respectively<br />
(Table II).<br />
Stroke patients’ experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT 3<br />
Knowledge <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an<br />
easier life<br />
The <strong>in</strong>formants stated that lower-limb CIMT,<br />
through <strong>in</strong>tensive repetition both <strong>in</strong> the tra<strong>in</strong><strong>in</strong>g<br />
<strong>and</strong> <strong>in</strong> the <strong>in</strong>formation/education, gave them <strong>knowledge</strong><br />
about themselves <strong>and</strong> the function <strong>of</strong> their<br />
bodies. This <strong>knowledge</strong> helped them to live their<br />
lives more easily. They felt that there was still hope<br />
<strong>and</strong> possibilities for functional improvements, which<br />
gave them <strong>in</strong>creased <strong>in</strong>dependence <strong>and</strong> self-esteem.<br />
But when I look back on CIMT, I see that ...it<br />
was this that <strong>in</strong> fact changed everyth<strong>in</strong>g, it made<br />
th<strong>in</strong>gs really great. [I:5]<br />
The therapy<br />
The ma<strong>in</strong> category the therapy comprised the <strong>in</strong>formant’s<br />
experiences <strong>of</strong> the preparations for CIMT,<br />
the actual <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g, its effects <strong>and</strong> their<br />
views <strong>of</strong> the physiotherapists who conducted CIMT.<br />
Preparation. The preparation for CIMT was considered<br />
important for all <strong>in</strong>formants. S<strong>in</strong>ce the lowerlimb<br />
CIMT <strong>in</strong>volve hard <strong>and</strong> <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g, it<br />
was important to accept this <strong>and</strong> be prepared for it to<br />
be tough. Three <strong>of</strong> the <strong>in</strong>formants had previous<br />
experience <strong>of</strong> CIMT for the upper extremity <strong>and</strong><br />
they felt that their earlier experiences were crucial for<br />
how they could benefit from the lower-limb therapy.<br />
The others felt they could have benefited even more<br />
from the therapy a second time, when they knew<br />
what was required <strong>of</strong> them. Dur<strong>in</strong>g the preparations,<br />
goals <strong>and</strong> goal images were identified by the participants<br />
themselves, as part <strong>of</strong> the motivation process<br />
to give them strength for the <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g. The<br />
preparation was also important for others, as well as<br />
for the <strong>in</strong>formants.<br />
...Then you had to go to an <strong>in</strong>formation meet<strong>in</strong>g<br />
<strong>and</strong> take a relative with you because these relatives<br />
must also accept that it’s go<strong>in</strong>g to be so tough.<br />
[I:5]<br />
Table II. Stroke patients’ experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower limb CIMT: Theme, ma<strong>in</strong> categories <strong>and</strong> categories derived from analys<strong>in</strong>g<br />
<strong>in</strong>terviews.<br />
Theme Knowledge <strong>of</strong> <strong><strong>my</strong>self</strong> <strong>and</strong> <strong>my</strong> prospects for lead<strong>in</strong>g an easier life<br />
Ma<strong>in</strong> category The therapy Me <strong>and</strong> <strong>my</strong> body<br />
Categories Preparation The tra<strong>in</strong><strong>in</strong>g Effects Physiotherapists Motive force Changes Frustration
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4 I. Marklund et al.<br />
The tra<strong>in</strong><strong>in</strong>g. The tra<strong>in</strong><strong>in</strong>g was experienced as concentrated,<br />
<strong>in</strong>tensive <strong>and</strong> challeng<strong>in</strong>g, s<strong>in</strong>ce each<br />
exercise was always at the limit <strong>of</strong> each <strong>in</strong>dividual’s<br />
ability <strong>and</strong> capacity. The tra<strong>in</strong><strong>in</strong>g was strenuous, but<br />
by focus<strong>in</strong>g on the basis <strong>of</strong> what each <strong>in</strong>dividual<br />
could manage, <strong>and</strong> with a clear objective, the<br />
<strong>in</strong>formants were able to carry out lower-limb<br />
CIMT. Restriction, with the whole leg orthosis, <strong>of</strong><br />
the ‘‘healthy’’ extremity dur<strong>in</strong>g the tra<strong>in</strong><strong>in</strong>g, compelled<br />
the <strong>in</strong>formants to use the weak leg more than<br />
formerly. This was an important part <strong>of</strong> the tra<strong>in</strong><strong>in</strong>g,<br />
s<strong>in</strong>ce it showed them what compensatory patterns<br />
they had become accustomed to use. The restriction<br />
also clarified for the <strong>in</strong>formants, what function they<br />
still had <strong>in</strong> the afflicted leg.<br />
A spl<strong>in</strong>t like this on this one (the healthy leg)<br />
suddenly makes you see what a big difference<br />
there is <strong>in</strong> how your legs function. [I:7]<br />
The tra<strong>in</strong><strong>in</strong>g consisted largely <strong>of</strong> learn<strong>in</strong>g new ways<br />
<strong>of</strong> do<strong>in</strong>g th<strong>in</strong>gs, e.g. learn<strong>in</strong>g to walk <strong>in</strong> a new way,<br />
<strong>and</strong> do th<strong>in</strong>gs the <strong>in</strong>formants did not believe they<br />
would manage. This compelled both body <strong>and</strong><br />
bra<strong>in</strong>. They experienced a feel<strong>in</strong>g <strong>of</strong> be<strong>in</strong>g ‘‘entirely<br />
empty-headed’’ dur<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g, <strong>and</strong> that the bra<strong>in</strong><br />
‘‘protested’’.<br />
And then the feel<strong>in</strong>g, that you pressurise all your<br />
senses <strong>and</strong> all your muscles so much <strong>and</strong> yes these<br />
are really th<strong>in</strong>gs you’ve never done before. [I:6]<br />
To carry out CIMT, backup <strong>and</strong> support at home<br />
were needed. This <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g <strong>in</strong>volved such<br />
physical exertion that it was hard to keep up social<br />
activities dur<strong>in</strong>g the CIMT period. To complete the<br />
therapy, it was required that CIMT had the top<br />
priority <strong>and</strong> everyth<strong>in</strong>g else had to be cut out.<br />
Yes but I <strong>got</strong> help both from the home-help <strong>and</strong><br />
from <strong>my</strong> friends ...but I <strong>got</strong> so enormously tired<br />
it frightened me. [I:2]<br />
Dur<strong>in</strong>g the tra<strong>in</strong><strong>in</strong>g, high dem<strong>and</strong>s were required <strong>in</strong><br />
each exercise at high pace, which was experienced as<br />
extremely tough. The tra<strong>in</strong><strong>in</strong>g was always at the limit<br />
<strong>of</strong> the patients’ capacity. The strong group feel<strong>in</strong>g<br />
gave the <strong>in</strong>formants the strength to manage one<br />
more day. That the tra<strong>in</strong><strong>in</strong>g was conducted <strong>in</strong> an<br />
adapted environment, even though <strong>in</strong> cramped<br />
premises, was felt to be stimulat<strong>in</strong>g.<br />
Effects. The physical effects <strong>of</strong> the lower-limb CIMT<br />
were described <strong>in</strong> various ways: stronger legs, better<br />
balance, ‘‘I manage more <strong>and</strong> I use the leg more than<br />
before’’. Tra<strong>in</strong><strong>in</strong>g effects were experienced partly<br />
dur<strong>in</strong>g the CIMT period, but also later on. The<br />
therapy gave a positive experience <strong>of</strong> be<strong>in</strong>g able to<br />
trust the leg more <strong>and</strong> feel like a fully capable person<br />
who could walk faster, almost normally, with a new<br />
gait technique.<br />
It’s start<strong>in</strong>g to come bit by bit, afterwards, now;<br />
<strong>and</strong> above all I feel <strong>my</strong> right leg is as strong as <strong>my</strong><br />
left so that I can rely on it more. [I:3]<br />
Feel<strong>in</strong>gs <strong>and</strong> expressions such as ‘‘quite fantastic,<br />
overwhelm<strong>in</strong>g, a feel<strong>in</strong>g <strong>of</strong> freedom’’ that outweighed<br />
all the hard work <strong>and</strong> an experience that<br />
the body was recover<strong>in</strong>g faster than the bra<strong>in</strong>,<br />
emerged at the same time as the <strong>in</strong>formants became<br />
aware <strong>of</strong> how fragile <strong>and</strong> exposed their situation<br />
were.<br />
This is what <strong>my</strong> body needed. [I:6]<br />
Physiotherapists. The <strong>in</strong>formants reported that the<br />
physiotherapists <strong>and</strong> their work were very pr<strong>of</strong>essional.<br />
They had great competence, were sensitive to<br />
changes, were at the same time ‘‘shar<strong>in</strong>g their lives’’,<br />
<strong>and</strong> were participat<strong>in</strong>g <strong>in</strong> all activities dur<strong>in</strong>g the day.<br />
The physiotherapists were seen as responsible for<br />
control <strong>and</strong> discipl<strong>in</strong>e, by cont<strong>in</strong>ually modify the<br />
tra<strong>in</strong><strong>in</strong>g. They made dem<strong>and</strong>s, spurred on, gave<br />
positive feedback, encouraged <strong>and</strong> confirmed; <strong>and</strong><br />
this made the <strong>in</strong>formants feel that their work was<br />
strenuous. The physiotherapists clearly focused on<br />
mak<strong>in</strong>g every participant better on the basis <strong>of</strong> his or<br />
her own potential.<br />
They jo<strong>in</strong> <strong>in</strong> <strong>and</strong> we eat together <strong>and</strong> they jo<strong>in</strong> <strong>in</strong><br />
all the time <strong>and</strong> they’re on to you, you can hardly<br />
cheat on anyth<strong>in</strong>g without them turn<strong>in</strong>g up. [I:7]<br />
Me <strong>and</strong> <strong>my</strong> body<br />
The ma<strong>in</strong> category me <strong>and</strong> <strong>my</strong> body comprised the<br />
<strong>in</strong>formants’ reflections on their own significance <strong>in</strong><br />
the therapy, how this affected them <strong>and</strong> what <strong>in</strong>sight<br />
on their situation it gave them.<br />
Motive force<br />
The <strong>in</strong>formant’s motivation, persistence, desire to<br />
tra<strong>in</strong> <strong>and</strong> the fact that they themselves made the<br />
decision to take part, were important aspects for<br />
complet<strong>in</strong>g CIMT. They felt that they were specially<br />
chosen <strong>and</strong> made the effort s<strong>in</strong>ce few had the<br />
opportunity to undergo this therapy. By mak<strong>in</strong>g<br />
priorities <strong>and</strong> giv<strong>in</strong>g themselves time to work <strong>in</strong> a<br />
goal-oriented way, they managed to complete<br />
CIMT.
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I th<strong>in</strong>k you have to be selfish enough to focus on<br />
yourself. [I:4]<br />
Changes. The physical effects changed the <strong>in</strong>formants’<br />
view <strong>of</strong> their own capacity <strong>and</strong> gave a feel<strong>in</strong>g<br />
<strong>of</strong> human worth, <strong>of</strong> not be<strong>in</strong>g f<strong>in</strong>ished as a human<br />
be<strong>in</strong>g. By succeed<strong>in</strong>g <strong>in</strong> various exercises <strong>and</strong> reach<strong>in</strong>g<br />
their anticipated goals, they strengthened their<br />
self-esteem, <strong>and</strong> their belief <strong>in</strong> the future was<br />
aroused. The <strong>knowledge</strong> the <strong>in</strong>formants ga<strong>in</strong>ed<br />
about their bodies dur<strong>in</strong>g CIMT, gave them security<br />
<strong>in</strong> their daily liv<strong>in</strong>g. Changes also concerned spread<strong>in</strong>g<br />
the <strong>knowledge</strong> <strong>and</strong> experience they ga<strong>in</strong>ed. It<br />
was important for the <strong>in</strong>formants to be able to report<br />
their experience <strong>and</strong> <strong>in</strong> this way <strong>in</strong>fluence the<br />
situation for others with stroke. They also felt that<br />
other people experienced them differently after the<br />
therapy.<br />
There’s lot <strong>of</strong>, I th<strong>in</strong>k, positive th<strong>in</strong>gs about<br />
work<strong>in</strong>g hard, too, partly because you get attention<br />
yourself <strong>and</strong> the help you need, but <strong>in</strong> this<br />
way you also get past these natural obstacles, you<br />
believe you’re go<strong>in</strong>g to manage th<strong>in</strong>gs yourself.<br />
You grow <strong>in</strong> yourself you recover a certa<strong>in</strong> position<br />
<strong>in</strong> your home. [I:4]<br />
Frustration. The <strong>in</strong>formants felt frustrated by the fact<br />
that few know about lower-limb CIMT <strong>in</strong> the<br />
healthcare system <strong>in</strong> Sweden. They considered<br />
CIMT should come early <strong>in</strong> the rehabilitation for<br />
everybody afflicted by stroke. Through reflection<br />
over their earlier rehabilitation, the <strong>in</strong>formants felt<br />
that the level was too low <strong>in</strong> traditional rehabilitation<br />
<strong>and</strong> they needed to ‘‘raise the bar’’. They said that<br />
‘‘overtra<strong>in</strong><strong>in</strong>g’’ was needed. They also want an<br />
overall programme from the start, s<strong>in</strong>ce stroke <strong>in</strong><br />
the acute stage to lifelong rehabilitation, so they can<br />
plan their future. In their frustration, there were also<br />
disappo<strong>in</strong>tments about the focus on manag<strong>in</strong>g as<br />
well as possible with the help <strong>of</strong> the ‘‘healthy’’ side <strong>in</strong><br />
the acute stage <strong>of</strong> rehabilitation, <strong>in</strong>stead <strong>of</strong> rehabilitat<strong>in</strong>g<br />
the ‘‘weak’’ side.<br />
I can’t underst<strong>and</strong> how they th<strong>in</strong>k, first they must<br />
rescue a person ...I mean we might well have<br />
died ...but then they sit there <strong>in</strong> the care system<br />
<strong>and</strong> save them, <strong>and</strong> then they tell you you must<br />
live; but you don’t get any help for liv<strong>in</strong>g. [I:7]<br />
Despite <strong>knowledge</strong> <strong>and</strong> experience <strong>of</strong> lower-limb<br />
CIMT, the <strong>in</strong>formants felt that they could not<br />
manage to tra<strong>in</strong> <strong>in</strong>tensively themselves: recurrent<br />
periods <strong>of</strong> lower-limb CIMT were needed. There<br />
emerged clearly a frustration that it is not even<br />
Stroke patients’ experience <strong>of</strong> tra<strong>in</strong><strong>in</strong>g with lower-limb CIMT 5<br />
possible to pay for it privately <strong>and</strong> a feel<strong>in</strong>g that the<br />
council for the healthcare system <strong>in</strong> Sweden was<br />
dragg<strong>in</strong>g its heels regard<strong>in</strong>g <strong>in</strong>troduction <strong>of</strong> new<br />
therapy methods.<br />
But can’t you pay, I asked, to get this therapy; but<br />
that was not possible either. [I:1]<br />
Discussion<br />
People who had had a stroke experienced that<br />
CIMT for the lower extremity gave them <strong>knowledge</strong><br />
about their body <strong>and</strong> their chances to be able to live<br />
their life more easily. The <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g gave<br />
them hope, s<strong>in</strong>ce the functional improvements<br />
showed opportunities <strong>of</strong> change that <strong>in</strong>creased their<br />
<strong>in</strong>dependence <strong>and</strong> self-esteem. Even though the<br />
<strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g, which cont<strong>in</strong>ued 6 h/day every<br />
day for 2 weeks is tough, it was experienced as<br />
entirely necessary.<br />
One weakness <strong>in</strong> the study is that the author (IM)<br />
who conducted the <strong>in</strong>terviews lacked earlier experience<br />
<strong>of</strong> qualitative studies. This was overcome partly<br />
by runn<strong>in</strong>g a trial <strong>in</strong>terview before the study, not<br />
<strong>in</strong>cluded <strong>in</strong> the results. The other authors (MK, BH)<br />
have experience <strong>of</strong> qualitative methods: their supervision<br />
<strong>and</strong> cont<strong>in</strong>ual co-operation dur<strong>in</strong>g the whole<br />
process strengthened the study’s trustworth<strong>in</strong>ess.<br />
A further weakness was that the material was small.<br />
S<strong>in</strong>ce there is very little CIMT for the lower<br />
extremity <strong>in</strong> Sweden <strong>and</strong> the authors should not<br />
know them before the study started, there were not<br />
many <strong>in</strong>formants to ask. However, the <strong>in</strong>formants<br />
were both men <strong>and</strong> women, <strong>in</strong> different ages, <strong>and</strong><br />
with variation <strong>in</strong> affected side <strong>and</strong> time s<strong>in</strong>ce stroke.<br />
Strength was that all authors were <strong>in</strong>volved <strong>in</strong> the<br />
analysis, open for the <strong>in</strong>formants’ experiences, <strong>and</strong><br />
reached consensus about the results. This <strong>in</strong>creased<br />
the credibility <strong>of</strong> the study. The audibility was<br />
enhanced by follow<strong>in</strong>g the steps <strong>in</strong> the analys<strong>in</strong>g<br />
process described by Graneheim & Lundman (22)<br />
<strong>and</strong> by giv<strong>in</strong>g quotations <strong>in</strong> the result section.<br />
Another strength was that the first author (IM)<br />
had many years experience <strong>of</strong> rehabilitat<strong>in</strong>g people<br />
with stroke, how various symptoms can be expressed<br />
emotionally <strong>and</strong> l<strong>in</strong>guistically. This simplified the<br />
<strong>in</strong>terview situation <strong>and</strong> the <strong>in</strong>formants were given<br />
scope to express themselves freely. On the other<br />
h<strong>and</strong>, the personal experience <strong>of</strong> the first author<br />
(IM) from the field reduces the possibilities <strong>of</strong> be<strong>in</strong>g<br />
open <strong>and</strong> unbiased vis-à-vis the <strong>in</strong>formants’ descriptions.<br />
Through close co-operation <strong>and</strong> discussion<br />
among the authors, the risk <strong>of</strong> subjective <strong>in</strong>terpretations<br />
was taken <strong>in</strong>to account (23).
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6 I. Marklund et al.<br />
Röd<strong>in</strong>g et al. (14) showed <strong>in</strong> their study the<br />
importance <strong>of</strong> underst<strong>and</strong><strong>in</strong>g <strong>and</strong> tak<strong>in</strong>g <strong>in</strong>to account<br />
the situation <strong>of</strong> the stroke-afflicted person<br />
when rehabilitation is be<strong>in</strong>g planned <strong>and</strong> conducted,<br />
so that it corresponds to the patient’s own priorities<br />
<strong>and</strong> needs. Stroke gives a multifaceted symptom<br />
depend<strong>in</strong>g on the localization <strong>of</strong> the damage. Therefore<br />
rehabilitation should be <strong>in</strong>fluenced by many<br />
perspectives <strong>and</strong> more based on the <strong>in</strong>dividual’s<br />
needs <strong>and</strong> potentials. The <strong>in</strong>formants <strong>in</strong> the present<br />
study expressed a need for more <strong>and</strong> repeated<br />
tra<strong>in</strong><strong>in</strong>g, even late after stroke onset, which also<br />
have been shown earlier (11,13). Frustration was<br />
expressed how the rehabilitation is planned <strong>and</strong><br />
conducted <strong>in</strong> Sweden. Even if the patients have the<br />
<strong>knowledge</strong> about how to tra<strong>in</strong>, the time <strong>and</strong> the<br />
necessary equipment, they still needed further<br />
supervision. This need <strong>of</strong> supervision <strong>and</strong> advice<br />
how to cont<strong>in</strong>ue tra<strong>in</strong><strong>in</strong>g was described already <strong>in</strong><br />
1995 by Lew<strong>in</strong>ter & Mikkelsen (24), but not much<br />
have changed accord<strong>in</strong>g to the stroke patients’<br />
experiences <strong>of</strong> gett<strong>in</strong>g the rehabilitation they need.<br />
To tra<strong>in</strong> 6 h/day, every day, <strong>in</strong> 2 weeks requires<br />
motivation, for both the patient <strong>and</strong> the relatives.<br />
Maclean et al. (25) showed <strong>in</strong> their study that highly<br />
motivated patients were more likely to view rehabilitation<br />
as the most important means to recovery <strong>and</strong><br />
to accord themselves an active role <strong>in</strong> rehabilitation.<br />
They also showed that <strong>in</strong>formation from pr<strong>of</strong>essionals<br />
about rehabilitation had a positive effect on<br />
motivation. In this study, the <strong>in</strong>formants <strong>and</strong> their<br />
relatives met the physiotherapists before CIMT<br />
started <strong>and</strong> received <strong>in</strong>formation about the therapy<br />
<strong>and</strong> what was expected from them. This procedure<br />
<strong>in</strong>creased the <strong>in</strong>formants’ motivation <strong>and</strong> emerges as<br />
a part <strong>of</strong> the result. The preparation was important<br />
for all the <strong>in</strong>formants <strong>and</strong> their relatives <strong>in</strong> the<br />
success <strong>of</strong> complet<strong>in</strong>g the <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g.<br />
Evidence exists that more <strong>in</strong>tensive exercise therapy<br />
is beneficial, but it is still unknown how<br />
<strong>in</strong>tensively <strong>and</strong> which subgroup benefits most. Van<br />
Peppen et al. (26) <strong>and</strong> Young & Forster (27) showed<br />
<strong>in</strong> their review articles the evidence for different<br />
types <strong>of</strong> rehabilitation after stroke. Strong evidence<br />
was found for strengthen<strong>in</strong>g the lower paretic limb<br />
<strong>and</strong> for task-oriented exercise tra<strong>in</strong><strong>in</strong>g to restore<br />
balance <strong>and</strong> gait. In addition, strong evidence<br />
emerged for improved symmetry <strong>in</strong> the tra<strong>in</strong><strong>in</strong>g <strong>of</strong><br />
ris<strong>in</strong>g from sitt<strong>in</strong>g to st<strong>and</strong><strong>in</strong>g, an exercise that is<br />
tra<strong>in</strong>ed frequently <strong>in</strong> CIMT for the lower extremity.<br />
If one adds what Kwakkel et al. (9) showed back <strong>in</strong><br />
1997, that <strong>in</strong>tensity is significant for the effect <strong>of</strong><br />
rehabilitation, then one has obta<strong>in</strong>ed most <strong>of</strong> the<br />
different exercises <strong>in</strong>cluded <strong>in</strong> CIMT for the lower<br />
extremity, as the present <strong>in</strong>formants confirmed when<br />
they reported that their paretic leg became stronger<br />
<strong>and</strong> that they could walk further <strong>and</strong> be<strong>in</strong>g able to<br />
trust the weak leg more.<br />
Despite a number <strong>of</strong> studies show<strong>in</strong>g that CIMT<br />
for the upper extremity gives positive results, no firm<br />
conclusions can be drawn, s<strong>in</strong>ce there are, so far, too<br />
few r<strong>and</strong>omized controlled trials (28). One problem<br />
is that the studies now available use different<br />
evaluation <strong>in</strong>struments. Another problem is that<br />
the therapy is not comparable, s<strong>in</strong>ce different<br />
<strong>in</strong>tensities, different number <strong>of</strong> tra<strong>in</strong><strong>in</strong>g hours/day<br />
<strong>and</strong> number <strong>of</strong> days/weeks are used. Attempts are<br />
also be<strong>in</strong>g made to arrive at what item <strong>of</strong> CIMT for<br />
the upper extremity is most important for the<br />
positive effects. Effort has been made to f<strong>in</strong>d out<br />
whether it is the actual restriction <strong>of</strong> the ‘‘healthy’’<br />
limb (29), the <strong>in</strong>tensity <strong>in</strong> time (30,31), the significance<br />
<strong>of</strong> treat<strong>in</strong>g <strong>in</strong>dividually or <strong>in</strong> group (32), or<br />
whether it is the shap<strong>in</strong>g exercises (33), that are most<br />
important for the improvements. In the present<br />
study, the <strong>in</strong>formants reported their experiences<br />
that it was their bra<strong>in</strong>s that were be<strong>in</strong>g tra<strong>in</strong>ed,<br />
that the <strong>in</strong>tensive tra<strong>in</strong><strong>in</strong>g was at the limit <strong>of</strong> their<br />
capability, that they experienced an ‘‘empt<strong>in</strong>ess’’ <strong>in</strong><br />
their head <strong>and</strong> that it was this that brought about the<br />
change.<br />
In rehabilitation, there is a meet<strong>in</strong>g between the<br />
therapist <strong>and</strong> the patient, <strong>and</strong> the <strong>in</strong>teraction between<br />
them is surely <strong>of</strong> great importance for the<br />
result. We need not only to underst<strong>and</strong> the disease,<br />
but also the patient, <strong>and</strong> here qualitative studies are<br />
at to a strength. Every rehabilitation situation is<br />
about more than medically, physically measurable<br />
effects: it also concerns communication experience,<br />
expectations, attitudes <strong>and</strong> desires (34). Regard<strong>in</strong>g<br />
lower-limb CIMT, there is an <strong>in</strong>teraction between<br />
the therapist <strong>and</strong> the patient dur<strong>in</strong>g 6 h/day, for<br />
2 weeks. Hence contact is both developed <strong>and</strong><br />
deepened. An <strong>in</strong>creased exchange <strong>of</strong> <strong>knowledge</strong>, a<br />
process <strong>of</strong> learn<strong>in</strong>g, is a natural element as there are<br />
opportunities for feedback directly <strong>in</strong> all situations.<br />
A Cochrane review has shown (35) that stroke<br />
survivors <strong>and</strong> their carers <strong>of</strong>ten feel they have not<br />
been given enough <strong>in</strong>formation about stroke <strong>and</strong><br />
they feel unprepared for life after discharge from<br />
hospital. There was also some evidence that when<br />
<strong>in</strong>formation is provided <strong>in</strong> a way that more actively<br />
<strong>in</strong>volved patients <strong>and</strong> cares by <strong>of</strong>fer<strong>in</strong>g repeated<br />
opportunities to ask questions patients’ mood<br />
was positively affected (35). In the present study,<br />
<strong>knowledge</strong> emerged as a constant theme that was<br />
important for all the <strong>in</strong>formants, that they had<br />
opportunities <strong>of</strong> ask<strong>in</strong>g the same physiotherapist<br />
the same questions aga<strong>in</strong> <strong>and</strong> aga<strong>in</strong>. The <strong>in</strong>formants<br />
needed to deepen their <strong>knowledge</strong> <strong>of</strong> their own<br />
bodies <strong>and</strong> how they functioned after stroke. Yet<br />
<strong>knowledge</strong> alone was not sufficient: feel<strong>in</strong>g at the
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same time what was happen<strong>in</strong>g <strong>in</strong> their bodies when<br />
they were tra<strong>in</strong><strong>in</strong>g, they learned new techniques <strong>and</strong><br />
tried th<strong>in</strong>gs they had not done earlier, thus obta<strong>in</strong><strong>in</strong>g<br />
a tool (<strong>knowledge</strong> <strong>and</strong> security) for use <strong>in</strong> daily<br />
liv<strong>in</strong>g. They learned, for example, both how gait<br />
is produced purely technically <strong>and</strong> how their<br />
bodies should sense when they were walk<strong>in</strong>g correctly.<br />
Different cognitive impairments follow<strong>in</strong>g<br />
stroke can affect learn<strong>in</strong>g ability, <strong>and</strong> this places<br />
high dem<strong>and</strong>s on the treat<strong>in</strong>g physiotherapist’s<br />
competence <strong>and</strong> ability to vary the methods <strong>of</strong><br />
learn<strong>in</strong>g employed.<br />
Even though tra<strong>in</strong><strong>in</strong>g after stroke is an area with<br />
relatively much research, the present results suggest<br />
that there may be reasons for further ref<strong>in</strong>ement <strong>of</strong><br />
the methods used.<br />
However, one issue that needs further elucidation<br />
is to identify <strong>in</strong> what sense <strong>knowledge</strong> <strong>and</strong> <strong>in</strong>teraction,<br />
between the patient who participate <strong>in</strong> CIMT<br />
<strong>and</strong> the physiotherapists, are significant for lowerlimb<br />
CIMT. More studies <strong>of</strong> CIMT for the lower<br />
extremity should be conducted. Quantitative studies<br />
to clarify the long-term effects <strong>of</strong> lower-limb CIMT<br />
<strong>and</strong> cost-effectiveness compared to qualities <strong>of</strong> life <strong>in</strong><br />
persons with stroke must be done. With qualitative<br />
studies, the phenomena frustration <strong>and</strong> motivation<br />
can be expla<strong>in</strong> <strong>and</strong> understood.<br />
Ac<strong>knowledge</strong>ments<br />
We thank the <strong>in</strong>formants who so generously shared<br />
their experiences with us. We also want to thank<br />
Annika Sefastsson <strong>and</strong> Sara Vive at Katar<strong>in</strong>akl<strong>in</strong>iken,<br />
Stockholm, Sweden, for their support. The<br />
study was supported with grants from Research <strong>and</strong><br />
Public Health <strong>and</strong> the Research Centre for Primary<br />
Care, Värml<strong>and</strong> County Council, Karlstad, Sweden<br />
<strong>and</strong> the Enoch Danielsson Foundation, Torsby,<br />
Sweden.<br />
Conflict <strong>of</strong> <strong>in</strong>terest:<br />
None declared.<br />
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