Disability & Rehabilitation, 2012; 34(8): 665–670 Copyright © 2012 Informa UK, Ltd. ISSN 0963-8288 print/ISSN 1464-5165 online DOI: 10.3109/09638288.2011.615373

RESEARCH PAPER

Fatigue after stroke: manifestations and strategies Marit Kirkevold1,2, Doris Christensen3, Grethe Andersen3, Søren Paaske Johansen3 & Ingegerd Harder1 Department of Public Health, Aarhus University, Århus, Denmark, 2Institute for Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, and 3Department of Neurology, Aarhus University Hospital, Århus, Denmark Disabil Rehabil Downloaded from informahealthcare.com by University of Alberta on 03/25/12 For personal use only.

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Implications for Rehabilitation

Purpose: To describe how fatigue is experienced by stroke survivors, how they understand and deal with fatigue and how fatigue impacts their daily life. Method: A qualitative interview study was carried out as part of a larger longitudinal study investigating the prevalence, characteristics and contributing factors to post-stroke fatigue. Thirty-two participants (15 men and 17 women) were strategically sampled to explore the experiences of fatigue. Participants were interviewed at 6 months, 1 year and 2 years post-stroke. Data were analysed applying a Grounded theory approach. Results: Patients clearly described and differentiated their experience between: (1) tiredness as an ordinary life event and (2) fatigue as a poststroke life condition. Three fatigue-transforming strategies were identified, being on a mission, settling for less and stalling. Stalling seemed to put the stroke survivors in a particularly vulnerable situation. Over time, some participants moved between these two tiredness/fatigue manifestations and their range of strategies. Conclusions: Post-stroke fatigue is a new life experience different from ordinary tiredness and seems to be a significant problem in the stroke survivors’ struggle to regain a new normalcy. Intervention studies are needed to reduce the impact of post-stroke fatigue on coping and recovery.

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Fatigue is a common experience following stroke that may have major impact on rehabilitation, coping and quality of life. r
The experienced impact of fatigue varies widely. r
Stroke survivors exhibit different coping approaches and strategies to manage the consequences of fatigue. For some, fatigue threatens their ability to cope. r
Tailored educational and support programs are needed to support fatigued stroke survivors at risk. The review found that post-stroke fatigue is a frequent phenomenon but that our understanding of the characteristics, mechanisms of occurrence, important contributing factors, co-occurring problems and consequences for the stroke survivors’ functioning and quality of life is lacking. Most of the studies conducted so far have used quantitative methods, applying mostly unidimensional scales to measure post-stroke fatigue. A recent study [12] explored post-stroke fatigue as a multidimensional phenomenon and found that, compared with the general population, stroke survivors experienced significantly more physical fatigue although their level of mental fatigue and motivation were comparable to that of the general population. This study, which followed the stroke survivors over 2 years, found that 59%, 44%, 38% and 40% of the stroke survivors experienced fatigue at 10 days, 3 months, 12 months and 2 years post-stroke. There was a significant decrease in fatigue within the first 3 months, but thereafter the level stayed constant. The factor most consistently correlated to post-stroke fatigue was poor functional status. In contrast to most studies, depression was not related to poststroke fatigue in this study, probably because of systematic anti-depressive treatment in this population. Very few studies have explored the experience of fatigue post-stroke using qualitative designs. Bendz [13], who

Keywords: Stroke, fatigue, stroke recovery, qualitative method

Introduction Despite the fact that fatigue is a common complaint among stroke survivors, reported by 40–74% [1–8], little is known about how post-stroke fatigue is experienced and its impact on the process of recovery following a stroke. During the last 10 years, several studies have tried to assess the prevalence of post-stroke fatigue [1–10] and to identify possible contributing factors [1–8]. A recent systematic review [11], based on 34 empirical studies published between 1997 and 2008, concluded that this area of research is still in its infancy.

Correspondence: Marit Kirkevold, Institute for Health and Society, Faculty of Medicine, University of Oslo, P.O. Box 1120, Blindern Oslo, NO 0318, Norway. Tel: (47) 22 85 05 69. Cell phone: (47) 95 76 68 30. Fax: (47) 22 85 05 70. E-mail: [email protected] (Accepted August 2011)

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explored the implications of having a stroke among 15 patients, applying a phenomenographic approach, found that fatigue influenced the rehabilitation process. Post-stroke fatigue was experienced as a new type of fatigue that came suddenly and without any specific reason, often with the health care workers paying little attention to the patients’ fatigue. In a Grounded Theory (GT) study of mild stroke, Carlsson et al. [14] found that mental fatigue was the most common symptom and that fatigue impacted on the independence and performance of activities among stroke survivors. Röding et al. [15] explored the experiences of younger stroke patients, using a GT approach, and found that fatigue was an overwhelming and uncontrollable part of their lives impacting on many aspects of life and functioning. These studies indicate that fatigue following a stroke may have a significant impact on the rehabilitation process and life of stroke survivors. However, little is known about how post-stroke fatigue is experienced over time and how stroke survivors conceptualize this phenomenon and seek to deal with it. To address these issues, the aim of this study was to describe how fatigue is experienced by stroke survivors, how they understand and deal with fatigue and how fatigue impacts on their daily life. We applied the following working definition of post-stroke fatigue: a profound sense of tiredness, lack of energy, and feeling of exhaustion following an acute stroke [7,11].

Method This qualitative interview study is part of a larger investigation of fatigue after stroke [12]. One hundred sixty five first ever stroke patients recruited at the Aarhus University Hospital, Denmark, were systematically followed at 10 days, 3 months, 1 year and 2 years after the stroke. The main questionnaire used was the Multidimensional Fatigue Inventory (MFI-20) covering five dimensions of fatigue: general fatigue, physical fatigue, mental fatigue, reduced motivation, and reduced activity. Scores per item run from 1 to 5, a maximum subscale score of 20 points indicates a high degree of fatigue. In this qualitative part of the study we used a cutoff score ≥12 on the general fatigue subscale, to distinguish between fatigued and non-fatigued patients, in line with previous studies [12,16].

Participants We aimed at a sample of 30 participants out of the total of 165 patients, including both “fatigued patients” (defined as a MFI-20 general fatigue score ≥12) and “non-fatigued patients” (defined as a general fatigue score <12) recorded at the 3-month follow-up in the main study. The reason for this sampling strategy was to look for significant differences and similarities across participants reporting fatigue and those that did not on the standardized fatigue instrument, and to explore details and variations of subjective experiences of fatigue. All stroke patients, enrolled in the main study, were consecutively invited to participate in the qualitative part of the study if they were able to communicate and did not have dementia or other severe cognitive impairment. The final number of participants taking part in the qualitative

part of the study was 32, of whom 10 had been treated with thrombolysis, 15 men and 17 women, 12 fatigued (general fatigue score ≥12) and 20 non-fatigued (general fatigue score <12). At 6 months 32 interviews were conducted. At 1 year 31 interviews were conducted; one patient was not interviewed due to severe illness. At 2 years, 26 interviews were conducted; one patient had died, one had developed dementia, one was too ill, one was not located and two declined participation.

Data collection Qualitative, thematic interviews were conducted 6 months, 1 year and 2 years after the stroke. Participants were asked to describe their experiences, if any, of post-stroke tiredness and fatigue. They were asked to exemplify the impact of tiredness and fatigue on their everyday life, explain how they managed or coped with the situation, and what kind of help or support they might have received. Ninty percent of the interviews took place in the participants’ home, the rest in the neurological outpatient clinic. The interviews were tape recorded and transcribed verbatim by the interviewer (DC). Ethical considerations The local ethics committee had approved the main study and all patients agreeing to participate in the qualitative interviews signed an additional informed consent, specifically developed for this part of the study (J no. 20030012). Data analysis A Grounded Theory approach guided the analysis [17,18] through a process of coding and writing memos, aiming at constructing a tentative theory of post-stroke fatigue. First, each interview was read several times to get an initial overall impression of the experiences conveyed. This first analytic step suggested that experiences of fatigue varied greatly among the participants and confirmed our assumption that both tiredness and fatigue had to be considered in order to capture their experiences. Second, the interviews were coded in detail with the aim of identifying the characteristics of tiredness and fatigue as described by the participants and their ways of handling these experiences in everyday life. We looked for answers to questions such as what characterizes the phenomena, when do they occur, under what conditions, with what consequences? Next, the codes from the interviews were compared and contrasted to look for similarities and differences in the answers to these questions across individuals and across time. The analysis continued along these lines until the dimensions of the experience, meaning and process of handling tiredness and fatigue were identified. Two of the authors (M.K. and I.H.) did the initial analysis independently and then compared and contrasted their initial findings. The level of agreement was high, but through a dynamic process over time, moving between individual and mutual analysis and reflection, we further refined our understanding of what was going on and how to best capture the processes identified. The final results are based on a carefully achieved consensus, critically reviewed by the other authors for internal and external validity. Disability & Rehabilitation

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Results Early in the analysis it became clear that for all participants, in various ways and in various degrees of awareness, their major, overriding rehabilitation goal was “striving for a new normalcy.” They tried to manage their own and others’ high expectations of getting well and return to live as before. This was described as a constant challenge. In order to describe fatigue, understand how it was managed and its impact on life, it had to be analysed within the context of working towards this long-term goal. The concept of fatigue was in itself a challenge. In Danish, the word tiredness covers a broad range of experiences and fatigue is not a term in common use. Consequently, tiredness was the word of choice for most participants when describing their experiences. On the other hand, they frequently underscored that the tiredness they experienced was new and different from the tiredness they were familiar with from before the stroke. It became apparent that both ordinary tiredness and unusual tiredness (fatigue) were present in the lives of many of the participants. Furthermore, these experiences could change over time. Tiredness and fatigue seemed to have a less negative impact on life as time passed. However, the opposite experience also occurred. For the individual participant, manifestations of tiredness or fatigue could change over time, and so did their strategies. It was not possible to identify typical trajectories directly from the individual stories, but overall our results suggest that the stroke patient’s initial reactions and initial strategies, regarding tiredness or fatigue, are keys to how they cope in daily life. Two major manifestations of tiredness and fatigue were identified: (1) tiredness as an ordinary life event and (2) fatigue as a post-stroke life condition. During the course of the 1½ years of follow-up interviews, some of the participants would move between these two tiredness/fatigue manifestations and their range of strategies. The data indicate a movement in both directions, that is some participants would struggle with post-stroke fatigue as a life condition for a while, then experience tiredness as a passing symptom that did not require much conscious effort or special strategies. Others experienced increasing fatigue over time.

Tiredness as an ordinary life event Tiredness as an ordinary life event presented itself on and off and as a well-known and passing experience. This meant seeing tiredness moments as being of minor importance, or certainly as being “bearable” and non-invasive in their lives. Still, tiredness was present in their lives now, in the context of having suffered a stroke: … tiredness is a relative thing, and one constantly compares with ones earlier life … so in terms of that, relatively speaking, I am not at all tired, but I am tired compared to my previous life (F416/24: 183–189).

The participants had many stories about tiredness. However, there were clear signs that they would brush off the tiredness and move on and that the familiarity of “being tired” became a foundation for anticipating and handling the tiredness: Copyright ©  Informa UK Ltd.

I was very tired after Christmas, I have to admit … but people who know me well say that I am always tired at that time of year (594/6, 16–18).

One overall strategy, “resting to recuperate,” was applied to deal with tiredness. This was a familiar strategy which for the stroke survivor was not troublesome, rather functioned as an effortless or even expedient act. By resting at times that fitted in, tiredness was not a major issue, even though they experienced it, and they developed ways of planning ahead that pushed tiredness into the background: If I do too much, then I get tired … if I am cleaning and continue for too long, then I get so tired that I have to go and sit down … that is the way it is (456/6, 43–48).

Fatigue as a post-stroke life condition Fatigue as a post-stroke life condition, on the other hand, presented itself on a more continuous basis and had a more profound impact on the lives of the stroke survivors. The unusual tiredness or fatigue could be experienced as primarily physical, primarily mental or both: But I am still very tired … I have started working part-time … and I sleep a lot. It feels a little like being over- medicated, I have very low blood pressure and tire very easily. (783/6, 15–20) … When I get tired … it feels like my body says that “now I can’t anymore” … my left leg starts to twist a lot … and it is as if my foot gets bigger … I simply lose the energy in my leg (783/6, 65–71). I find it very hard … it is more difficult now than immediately after I came home. It has dawned on me that I am handicapped … I get tired when I get out in the garden [and work] … and if I talk much I also get tired, because then I have to concentrate in order not to stumble (803/6, 16–25).

Mental fatigue was a new experience that the participants had difficulties explaining, but which for some impacted on what they could and could not do: Noise, loud music, that bothers me … The physician said that when we feel like this, we are “brain tired” … I can easily feel that I am in low gear … I can get on my bike and bicycle for 15 min, that does not make me tired. That helps on tiredness (266/6, 354–371).

Fatigue-transforming strategies The presence of fatigue triggered a variety of strategies that the individual stroke survivor would engage in. For some fatigue signalled a challenge to be faced and dealt with, like “being on a mission.” For others it meant a process of coming to terms with fatigue, “settling for less.” A third strategy was characterized by a process of “stalling” with a possibility of a painful giving up former energy or capacity to fulfill physical and psychosocial needs. The participants could move between these strategies along the illness trajectory. Being on a mission Participants being on a mission appeared highly motivated, mentally industrious, as well as physically active and were preoccupied with ways of regaining energy and actively facing fatigue, though at times they would put themselves over

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the limit. The participants performed physical, social and/or mental activities in measured doses to regain bodily strength and mental energy. Even when faced with experiences of fatigue on a daily basis, they were actively restructuring self and succeeded to win in their own way. They were driven by a will to reach a new normalcy and appeared prepared to go down new avenues to be able to do as before:

Short naps were often used. The participants “checked out” of activities or social engagements for a while, but were in control. Checking out was a temporary situation, where they would let go of mental and/or bodily efforts in the rehabilitation process and check back in. Resting became important to recharge batteries, a tool for normal or near-normal daily living:

The first month I was at home was difficult, very difficult … to find out things by myself, how to get things to work the way it had been before … to see that the things that used to be mine all of a sudden had become C’s (husband’s). But when I realized that I could manage, I found out getting the shopping and cooking done and everything … it took quite some time (266/6, 18–35).

… just as soon as I am to use … well, my energy … then I get tired … So if I do too much, then I get tired and have to … rest (456/6,71–73, 456/24,74–75).

I had to sort things out myself and I have tried to create a program, so I am trying to exercise everyday, something or another, I bicycle, I have a spinning bicycle … my daily program is always the same … get up, prepare for breakfast, get my tablets out … I do not get up too early … read the paper to maintain my reading ability … eat all the healthy stuff, all of this I concentrate on … But I have to make sure it is not all work here back home. I also want to followup on things I have been doing before, and go to the theatre, music, lectures … (266/6, 37–40, 160–176, 236–240). I: If you get tired, what do you do, do you go and take a nap? P: Well, sometimes I have gone back to bed, but I don’t do that anymore, so I might fall asleep reading the paper … . But I need to break this pattern, I am not a person who goes to bed and nap … (266/6, 303–313).

They worked hard to conquer their losses, mobilizing strength and skills to meet the challenges. Some would exert themselves, sparing no pains, to move the rehabilitation process forward. Transforming fatigue was part of this process.

Settling for less The participants settling for less accepted that fatigue was present in their life and that changes in their daily routines were necessary. Facing the constant challenge of managing high expectations for getting well and living as before, put pressure on them to find ways of handling daily experiences of “I can” and “I cannot.” This I can-I cannot relationship was demanding on some of the participants. However, settling for less meant that they felt being in control and able to handle fatigue as part of their conscious choices of how to spend time: If I don’t pull myself together, I’ll just sit in my chair. . .. Because I am not the same … so we have had to relax a bit on our plans … we were supposed to paint and so on the last 6 months … but it has come to nothing … and then it is like oh well … (485/6, 108–110, 123–127). I do feel like doing things still, but it is a little different than before … I am still very committed [to my work], I still feel very responsible, but not to the same degree as before (laughter) … and there are certain things, I won’t say I do things less … but I choose not to do certain things, those they have to sort out for themselves (485/6, 250–256). I let go of some things, I work a little more … indulgent … I don’t know … there are certain things I don’t want to be bothered with … I mean, I do care, but I can’t spend that much energy on it … what other people do or think … I just don’t care that much anymore … (485/24, 188–192).

It was clear from the participants’ stories that the individual person benefited from a support system, directly in the home or by some arrangement, privately or professionally. Dealing with fatigue became part of their every day routines involving not only the stroke survivor. Fatigue became manageable, when experiences of fatigue were acted upon with support: My husband helps a lot, he really does. He is so sweet, helps vacuum cleaning and everything … we do help each other … (456/24, 74–88).

These participants appeared to be on their way to settle for less and feel comfortable with this state of affairs as a dimension of their new normalcy.

Stalling Some participants wavered and would move back and forth between feelings of being in and out of control. For them, fatigue threatened to undermine their struggle for a new normalcy. Fatigue producing mechanisms were many, such as feeling pressure to move on, pushing oneself too hard or not knowing how to handle a situation. In these situations, fatigue preventing or relieving mechanisms could then be difficult to mobilize, as the following quote illustrates: I’d very much like to do everything at once … I have … in my head all the things that I’d like to do … and it really tires me that I don’t get to do them … because I’d so much like to sew, knit, crochet, make mosaics and a lot of other things … exercise and so on. I can do nothing, really … and I think sometimes … oh, what am I to do now (803/6, 249–255).

The participants tried to do their part and be industrious. However, they were walking a fine line, and they would sometimes falter: I am very tired … I have tried to change my rhythm of work somewhat … so that I don’t go 7 days on and 7 days off, but take some days in between…. But that has made things worse … because during the week I am off, I can concentrate on being off … but if I am going to work, let’s say Wednesday, Thursday, Friday … then I spend Monday and Tuesday resting … and then I work Wednesday, Thursday, Friday and am off work Saturday, Sunday, but I get nothing out of my spare time, because I am so exhausted … (783/12, 24–36).

A similar situation is described in the following fieldnote from one of the interviews: A is currently working 15 h a week, 5 h over 3 days. This is very burdensome for A. The days she is working, she is totally exhausted when she gets back home, she can barely cook and has to go to bed Disability & Rehabilitation

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early. She does not feel rested when she wakes up in the morning. As a consequence, her right arm becomes more spastic, her right leg needs a brace … and her pronunciation is getting worse. She simply feels that the days she is working disappear from the calendar and prevent her from doing what she wants, like having visits, read, be social. A proposal about working shorter hours over 4 days seems worse to her, as it will give her no time to recuperate (803/24, fieldnote).

For participants experiencing stalling, fatigue and the process towards a new normalcy were in conflict. It was difficult to transform the fatigue into a manageable and meaningful marker in their everyday life. Fatigue appeared to be illegitimate and unacceptable, for the participants themselves or for significant people in their surroundings. They were not in place, so to speak, and fatigue threatened to turn their lives into failure or defeat. The participants did not have the energy to get back on track, and fatigue became an enemy though resting would give some temporary relief. Support and direct help from significant others, “a soft place to fall,” and being surrounded by a sense of optimism appeared to be important, but frequently lacking aspects of their lives. Informed knowledge about bodily and mental signs of fatigue, and about possible coping techniques to overcome fatigue was not apparent in their stories.

Discussion We found that in order to understand how stroke survivors experience and manage post-stroke fatigue, it was necessary to contextualize their experiences within the overall recovery process following a stroke. Most studies focus on fatigue as an isolated illness related phenomenon [17,18]. Few studies have explored the experience of tiredness and fatigue within a wider context of the person’s life [17–19]. The major focus of our participants was their determined struggle to regain a new normalcy. Their experiences of tiredness and fatigue interacted with and impacted on this struggle in different ways. Two principally different experiences of tiredness were expressed; tiredness as an ordinary life event, similar to that experienced prior to the stroke and mitigated by the participants’ usual coping skills, and post-stroke fatigue as a unique phenomenon, requiring somewhat different coping techniques. Persons who experienced tiredness as an ordinary life event treated it as a marker for resting and expressed that they managed it well. Their recovery process did not seem unduly affected by the experienced tiredness. Persons who experienced post-stroke fatigue as something new and unique, reported that it did impact on the process of recovery. However, they approached this experience in very different ways. Some tried to win it over, others tried to renegotiate a new way of life taking the new phenomenon into account, and some seemed to be potentially “stuck” without finding a satisfying solution. Distinguishing between ordinary tiredness and post-stroke fatigue is important in rehabilitation practice in order to identify persons in need of education and support. A recent review concluded that health care professionals do not pay enough attention to fatigue and that systematic assessment and intervention is often not carried out [11]. Copyright ©  Informa UK Ltd.

In our main study [12], we found that fatigue decreased during the first post-stroke year, and that there was no significant change after 3 months. However, the average fatigue score remained above that of the normal population throughout the first 2 years. Our qualitative study shows that feeling fatigued is an aspect of post-stroke life to be reckoned with, and that the stroke survivor might struggle unnecessarily, trying to develop and maintain balanced reactions and actions. These findings suggest a need for early, focused intervention to address fatigue. So far, few tested interventions exist to assist rehabilitation professionals in supporting stroke survivors to relieve or manage fatigue [11]. The discovery of three patterns of fatigue work may help point towards possible support measures from health professionals and/or by family and friends. Stroke survivors “being on a mission” to conquer fatigue and the other consequences of their stroke seemed to be self-reliant and not in obvious need for support. However, they might potentially overexert themselves, and may need help to balance activity and rest to prevent injuries and impaired improvement. Stroke survivors “settling for less” in relation to the post-stroke fatigue might need help to evaluate whether they could in fact regain their strength through individually adjusted exercises or other coping approaches. Stroke survivors “stalling” were potentially overwhelmed by the post-stroke fatigue and seem particularly vulnerable and appear to receive inadequate help from outside. Actually, this latter group experienced that external forces frequently exaggerated the fatigue, often due to lack of understanding and support to renegotiate a new normalcy within the new parameters that the stroke had brought about. Consequently, health professionals need to be particularly sensitive to the need for support and assistance among this group. So far, however, few effective treatment options have been identified [11,20]. Previous research has found that professional support of stroke survivors encompass different types of interventions, including conserving the stroke survivors’ remaining functions, help interpret the new situation and its impact, console the stroke survivors’ in dealing with their losses and help integrate the changes into their present life situation [21]. We believe that these different aspects of support should guide the construction of fatigue specific programmes. Our previous findings [12] as well as those reported here, suggest the need for early screening, monitoring over time, and provision of fatigue preventive and fatigue transformative measures. Motivational interviewing [22] might be one effective element in a fatigue specific intervention programme, building on the stroke survivor’s apparent motivation and will to move forward. Fatigue has been found to be an independent determinant of not being able to resume paid work [23]. As our study and others [24] show, the incentive to move forward in life and go back to work, in a broad sense, is clearly there. However, although stroke survivors are mentally willing they feel “inadequately prepared” as found by Medin et al. [24], who point to fatigue as playing a major role and discuss a possible lack of participative rehabilitation programmes. We need to strengthen our efforts to assist the stroke survivors’ own

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coping abilities, paying special attention to fatigue. Going back to Nordenfelt’s [25] clinical commentary on the contribution of action theory, rehabilitation should focus both on supporting the person’s capacity (inner possibility) to act and the person’s opportunity (outer possibility) to act in specific contexts. This study had several strengths and weaknesses. Its strengths are that we strategically sampled participants to explore a broad range of post-stroke experiences of tiredness and fatigue and that we followed up stroke survivors over time to uncover how their experiences changed over time. Furthermore, collaborative analysis contributes to the validity of the findings. Weaknesses include the lack of concurrent data collection and analysis usually advised in GT studies. Theoretical sampling guided by preliminary findings might have provided us with a better basis for developing a grounded theory of post-stroke fatigue management. Despite these weaknesses, we believe this study contributes with important knowledge that may guide further research and rehabilitation practice in this area.

References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Conclusions Tiredness and fatigue are frequent experiences post-stroke. Whereas the experience of tiredness does not seem to impact unduly on the rehabilitation process, post-stroke fatigue might be a significant problem in the stroke survivors’ struggle to regain a new normalcy. Three different fatigue-transforming strategies were identified, of which stalling seemed to put the stroke survivors in a particularly vulnerable situation. Intervention studies are needed to assist rehabilitation professionals in supporting stroke survivors in reducing the impact of post-stroke fatigue on coping and recovery post-stroke.

13. 14. 15. 16. 17. 18. 19.

Acknowledgements We acknowledge the contribution of the stroke survivors sharing their experiences with us. We also acknowledge the Danish Research Fund, Aarhus University and Aarhus University Hospital for providing funding for the study and the leadership and professionals at Aarhus University hospital for assisting in recruiting participants to the study. Declaration of interest: This study was founded by the Danish Research Council, Aarhus University and Aarhus University hospital.

20. 21. 22. 23. 24. 25.

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