Presurgical sleep and pain behaviors predict insomnia symptoms and pain after total knee arthroplasty: a 12-month longitudinal, observational study.

OBJECTIVE: Up to 40% of individuals who undergo total knee arthroplasty (TKA) experience some degree of pain following surgery. Presurgical insomnia has been identified as a predictor of postsurgical pain; however, modifiable presurgical behaviors related to insomnia have received minimal attention. The objective of the present study was to develop a 2-item sleep and pain behavior scale (SP2) to investigate a maladaptive sleep and pain behavior and is a secondary analysis of a larger, parent study. METHODS: Patients (N = 109) completed SP2 at baseline and 12 months and questionnaires assessing sleep and pain at baseline (pre-TKA), 6 weeks, 3, 6, and 12 months post-TKA. SP2 demonstrated adequate preliminary psychometric properties. RESULTS: As hypothesized, even after controlling for baseline insomnia, pain, anxiety and other covariates, baseline SP2 predicted insomnia symptom severity at 6 weeks (ß = 2.828), 3 (ß = 2.140), 6 (ß = 2.962), and 12 months (ß = 1.835) and pain at 6 weeks (ß = 6.722), 3 (ß = 5.536), and 6 months (ß = 7.677) post-TKA (P < .05). Insomnia symptoms at 6-weeks post-TKA mediated the effect of presurgical SP2 on pain at 3 (95% CI: 0.024-7.054), 6 (95%CI: 0.495-5.243), and 12 months (95% CI: 0.077-2.684). CONCLUSIONS: This provides preliminary evidence that patients who cope with pain by retiring to their bed and bedroom have higher rates of post-surgical insomnia and pain and supports efforts to target this maladaptive sleep and pain behavior to reduce postsurgical pain.

Eliminating Sleep Health Disparities and Achieving Health Equity: Seven Areas for Action in the Behavioral Sleep Medicine Community.

Racial and ethnically minoritized and under-resourced populations do not reap the same benefits of sufficient sleep as their white counterparts resulting in insufficient sleep and sleep health disparities. Research exploring these disparities have documented a plethora of factors including social determinants of health, community violence, and structural issues - all of which are associated with adverse sleep. There are robust evidence base behavioral intervention that can be leveraged to improve sleep health among racial and ethnic groups. However, EBIs are not well leveraged. In 2021, with participation from members of the society of behavioral sleep medicine, we conducted this report to bring together the field of behavioral sleep medicine including researchers, clinicians and trainees to discuss gaps and opportunities at the intersection of the COVID-19 pandemic, systemic racism, and sleep health. The goals were anchored around seven recommendations toward reducing disparities in the near-term and longer-term approaches to eliminating disparities. Furthermore, we acknowledge that reducing and eliminating disparities in sleep health requires a multifaceted approach that includes a focus on individual, community, health care and societal levels of influence with participation from diverse partners including federal, state and local.

Illness Intrusiveness in Adults with Sickle Cell Disease: The Role of Fatigue.

Chronic illness experiences often interfere with daily functioning (a concept known as illness intrusiveness) and health-related quality of life (HRQoL). However, less is known about the role of specific symptoms in predicting illness intrusiveness in sickle cell disease (SCD). This exploratory study examined associations between common SCD-related symptoms (i.e., pain, fatigue, depression, and anxiety), illness intrusiveness, and HRQoL among adults with SCD (n = 60). Illness intrusiveness significantly correlated with fatigue severity (r = .39, p = .002), depression severity (r = .45, p < .001), anxiety severity (r = .41, p = .001), physical HRQoL (r = - .53, p < .001), and mental HRQoL (r = - .44, p < .001). Multiple regression revealed a significant overall model, (R2 = .28, F(4, 55) = 5.21, p = .001), with fatigue, but not pain, depression, or anxiety, significantly predicting illness intrusiveness (ß = .29, p = .036). Results suggest that fatigue may be a primary factor contributing to illness intrusiveness-a determinant of HRQoL-in individuals with SCD. Given the limited sample size, larger confirmatory studies are warranted.

Cognitive Assessment of Individuals with Multiple Sclerosis in the Arab World: a Systematic Review.

The prevalence of multiple sclerosis (MS) is on the rise globally, and recent epidemiological studies have observed increased rates in the Arab world (i.e., countries of North Africa and the Middle East where Arabic is the primary language). However, assessment of cognitive impairment and its relevant covariates (e.g., fatigue and depressive symptomatology) in the Arab world has not been rigorously reviewed. Thus, the objective of the present study was to systematically review the current use of cognitive assessment measures in observational and interventional studies of individuals with MS in the Arab world. A systematic review of studies that assessed cognitive function in adults with MS in the Arab world was conducted using PubMed, PsycINFO, CINAHL, The Cochrane Library, Embase, WHO Global Index Medicus, and Ovid Global Health. Studies that featured at least one objective cognitive measure were included. Eligible studies were reviewed for bias and study quality using the QUADAS-2 and NIH QAT. Study characteristics and finding were extracted by two independent reviewers, with results confirmed by a third reviewer. A total of 13 (N = 846) studies met inclusion criteria. Risk of bias and included measures varied across studies. Results demonstrated inconsistent availability and use of MS cognitive assessment tools across the Arab world. An Arabic version of the BICAMS was the only cognitive battery that was evaluated with regard to psychometric properties. The most common individual test include in reviewed studies was the SDMT. However, validation studies are still needed for this and a number of other measures. Other measures are still in the early stages of translation and cultural-linguistic norming. This review of cognitive assessment of individuals with MS in the Arab world was limited by variable study quality and measure selection. The present review provides a summary of the tests most commonly used in this region and recommendations for future investigation.

In vivo evidence of oxidative stress in brains of patients with progressive multiple sclerosis.

BACKGROUND: The oxidative stress hypothesis links neurodegeneration in the later, progressive stages of multiple sclerosis (MS) to the loss of a major brain antioxidant, glutathione (GSH). OBJECTIVE: We measured GSH concentrations among major MS subtypes and examined the relationships with other indices of disease status including physical disability and magnetic resonance imaging (MRI) measures. METHODS: GSH mapping was performed on the fronto-parietal region of patients with relapsing-remitting multiple sclerosis (RRMS, n = 21), primary progressive multiple sclerosis (PPMS, n = 20), secondary progressive multiple sclerosis (SPMS, n = 20), and controls ( n = 28) using GSH chemical shift imaging. Between-group comparisons were performed on all variables (GSH, T2-lesion, atrophy, Expanded Disability Status Scale (EDSS)). RESULTS: Patients with MS had substantially lower GSH concentrations than controls, and GSH was lower in progressive MS (PPMS and SPMS) compared with RRMS. GSH concentrations were not significantly different between PPMS and SPMS, or between RRMS and controls. Brain atrophy was significant in both RRMS and progressive MS compared with controls. CONCLUSION: Markedly lower GSH in progressive MS than RRMS indicates more prominent involvement of oxidative stress in the progressive stage of MS than the inflammatory stage. The association between GSH and brain atrophy suggests the important role of oxidative stress contributing to neurodegeneration in progressive MS, as suggested in other neurodegenerative diseases.

Sleep Disturbance and Cognitive Dysfunction in Multiple Sclerosis: a Systematic Review.

PURPOSE OF REVIEW: The present review summarizes recent research on the association between sleep disturbance and cognitive dysfunction in MS. Assessment methodology, domain-specific associations between sleep disturbance and cognitive dysfunction, and implications for future research and treatment are discussed. RECENT FINDINGS: All 12 studies included in this review found significant associations between sleep disturbance and cognitive dysfunction; however, results varied considerably depending on the assessment method used and the cognitive domain assessed. Self-reported sleep disturbance generally predicted self-report but not objective measures of cognitive dysfunction. Objective sleep measures (e.g., polysomnography, actigraphy) generally predicted objective impairments in processing speed and attention; however, objective sleep disturbance was more variable in predicting performance in other cognitive domains (e.g., memory, executive function). Sleep disturbance may help predict future cognitive decline in MS. Results highlight the need to integrate sleep assessment into routine MS care. Interventions aimed treating sleep disturbance may offer promise for improving cognitive dysfunction in MS.

Moderators of Treatment Outcomes After Telehealth Self-Management and Education in Adults With Multiple Sclerosis: A Secondary Analysis of a Randomized Controlled Trial.

OBJECTIVE: To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS. DESIGN: Secondary analysis of a single-blind randomized controlled trial. SETTING: Community. PARTICIPANTS: Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States. INTERVENTIONS: Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88). MAIN OUTCOME MEASURES: Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation). RESULTS: Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes. CONCLUSIONS: At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms.

Diagnostic and Clinical Utility of the GAD-2 for Screening Anxiety Symptoms in Individuals With Multiple Sclerosis.

OBJECTIVE: To assess the diagnostic and clinical utility of the 2-item Generalized Anxiety Disorder Scale (GAD-2) for screening anxiety symptoms in individuals with multiple sclerosis (MS). DESIGN: Cross-sectional. SETTING: University-affiliated MS neurology and rehabilitation center. PARTICIPANTS: The sample comprised adults (N=99) (ages 19-72; mean ± SD=46.2±13.0; 75% women) with a physician-confirmed MS diagnosis who were receiving care in a university-affiliated MS center. Disease durations ranged from 1 to 37 years (mean ± SD=10.7±8.4). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participants completed the 7-item Generalized Anxiety Disorder Scale (GAD-7) and GAD-2. Internal consistency was calculated for both measures. Area under the receiver operating characteristics curve (AUC), the 95% confidence interval for the AUC, and Youden's J were calculated to determine the optimal GAD-2 cutoff score for identifying clinically significant anxiety symptoms, as defined by the previously validated GAD-7 cutoff score of ≥8. RESULTS: Internal consistency was excellent for the GAD-7 (Cronbach α=.91) and acceptable for the GAD-2 (α=.77), and the measures were highly correlated (r=.94). The GAD-2 had excellent overall accuracy for identifying clinically significant anxiety symptoms (AUC=0.97; 95% confidence interval, 0.94-1.00). A GAD-2 cutoff score of ≥3 provided an optimal balance of good sensitivity (0.87) and excellent specificity (0.92) for detecting clinically significant anxiety symptoms. Alternatively, a cutoff score of ≥2 provided excellent sensitivity (1.00) and fair specificity (0.76). CONCLUSIONS: The GAD-2 is a clinically useful and psychometrically valid tool for screening anxiety symptoms in MS rehabilitation and neurology care settings. Importantly, this tool has the potential to identify individuals with MS who are at risk for anxiety disorders and who may benefit from rehabilitation psychology interventions to ultimately improve functioning and quality of life.

Association Between Sleep Problems and Perceived Cognitive Dysfunction Over 12 Months in Individuals with Multiple Sclerosis.

Sleep problems are highly prevalent among individuals with multiple sclerosis (MS); however, the relationship between sleep problems and cognitive dysfunction is poorly understood in this population. In the present study, 163 individuals with MS and depression, fatigue, or pain completed self-report measures of sleep, cognitive dysfunction, and relevant demographic and clinical characteristics (e.g., disability severity, depressive symptomatology, pain intensity, fatigue impact) at four time points over 12 months. Mixed-effects regression demonstrated that poorer sleep was independently associated with worse perceived cognitive dysfunction (ß = -0.05, p = .001), beyond the influence of depressive symptomatology. Fatigue impact was found to partially mediate this relationship. Results suggest that for individuals with MS and depression, fatigue, or pain, self-reported sleep problems are related to perceived cognitive dysfunction, and that fatigue impact accounts for part of this relationship.

Longitudinal changes of cerebral glutathione (GSH) levels associated with the clinical course of disease progression in patients with secondary progressive multiple sclerosis.

BACKGROUND: Increased oxidative stress leads to loss of glutathione (GSH). We have reported lower cerebral GSH in patients with secondary progressive multiple sclerosis (SPMS), indicating the involvement of oxidative stress in multiple sclerosis (MS) pathophysiology. OBJECTIVE: This study expanded upon our earlier work by examining longitudinal changes in cerebral GSH in patients with SPMS in relation to their clinical status. METHODS: A total of 13 patients with SPMS (Expanded Disability Status Scale (EDSS) = 4.0-6.5; MS duration = 21.2 ± 8.7 years) and 12 controls were studied over 3-5 years. GSH mapping was acquired from frontal and parietal regions using a multiple quantum chemical shift imaging technique at 3 T. Clinical assessments of the patient's disability included EDSS, gait, motor strength, ataxia, tremor, brainstem function and vision changes. RESULTS: Brain GSH concentrations in patients were lower than those in controls for both baseline and 3- to 5-year follow-ups. Longitudinal GSH changes of patients were associated with their neurologist's blinded appraisal of their clinical progression. Patients judged to have worsening clinical status had significantly greater declines in frontal GSH concentrations than those with stable clinical status. CONCLUSION: GSH provides a distinct measure associated with the disease progression in SPMS, possibly due to its dynamic alignment with pathogenic processes of MS related to oxidative stress.

Sleep and its associations with perceived and objective cognitive impairment in individuals with multiple sclerosis.

Problems with sleep and cognitive impairment are common among people with multiple sclerosis (MS). The present study examined the relationship between self-reported sleep and both objective and perceived cognitive impairment in MS. Data were obtained from the baseline assessment of a multi-centre intervention trial (NCT00841321). Participants were 121 individuals with MS. Nearly half (49%) of participants met the criteria for objective cognitive impairment; however, cognitively impaired and unimpaired participants did not differ on any self-reported sleep measures. Nearly two-thirds (65%) of participants met the criteria for 'poor' sleep, and poorer sleep was significantly associated with greater levels of perceived cognitive impairment. Moreover, the relationships between self-reported sleep and perceived cognitive impairment were significant beyond the influence of clinical and demographic factors known to influence sleep and cognitive functioning (e.g. age, sex, education level, disability severity, type of MS, disease duration, depression and fatigue). However, self-reported sleep was not associated with any measures of objective cognitive impairment. Among different types of perceived cognitive impairment, poor self-reported sleep was most commonly related to worse perceived executive function (e.g. planning/organization) and prospective memory. Results from the present study emphasize that self-reported sleep is significantly and independently related to perceived cognitive impairment in MS. In terms of clinical implications, interventions focused on improving sleep may help improve perceived cognitive function and quality of life in this population; however, the impact of improved sleep on objective cognitive function requires further investigation.

Resilience Mediates the Longitudinal Relationships Between Social Support and Mental Health Outcomes in Multiple Sclerosis.

OBJECTIVES: To investigate the longitudinal relationships between social support and subsequent mental health outcomes in individuals with multiple sclerosis (MS), and to examine resilience as a mediator between social support and subsequent mental health outcomes in this population. DESIGN: Observational, longitudinal cohort study. Participants were assessed at 4 time points over 12 months in the context of a previously reported randomized controlled trial. SETTING: Telephone-based measures administered to community-based participants. PARTICIPANTS: Individuals (N=163) with MS and 1 or more of the following symptoms: depression, fatigue, and pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mental health outcomes included (1) depressive symptomatology, assessed using the Patient Health Questionnaire-9; (2) anxious symptomatology, assessed using the short form of the Emotional Distress-Anxiety Scale from the Patient-Reported Outcomes Measurement Information System; and (3) general mental health status, assessed using the Mental Component Summary score from the Short Form-8 Health Survey. Resilience was assessed using the Connor-Davidson Resilience Scale. RESULTS: At any given time, social support from significant others, family members, and friends was significantly associated with subsequent mental health outcomes for all 3 measures assessed (all P values <.05). Resilience measured concomitantly with social support significantly mediated the relationships between social support and subsequent mental health outcomes. After controlling for resilience, most of the direct relationships between social support and mental health outcomes were no longer significant. CONCLUSIONS: There are significant longitudinal relationships between social support, resilience, and mental health outcomes for people with MS. Given the mediating role of resilience in supporting better mental health outcomes, future clinical research and practice may benefit from an emphasis on resilience-focused psychological interventions.

Mental Health Comorbidity in MS: Depression, Anxiety, and Bipolar Disorder.

Among individuals with multiple sclerosis (MS), mental health comorbidities play a significant role in contributing to secondary disability and detracting from quality of life. This review examines current evidence surrounding three mental health issues of particular relevance to MS: depression, anxiety, and bipolar disorder. We review what is known of the prevalence, correlates, screening mechanisms, and current treatment of each issue and provide recommendations for future areas of research.

Self-efficacy as a longitudinal predictor of perceived cognitive impairment in individuals with multiple sclerosis.

OBJECTIVES: To determine whether self-efficacy longitudinally predicts 2 types of perceived cognitive impairment (PCI) in multiple sclerosis (MS): general cognitive functioning and executive functioning; and secondarily to assess whether self-efficacy mediates the relationships between depression, fatigue, and PCI. DESIGN: Longitudinal analysis of self-report survey data collected over 3 years. Hierarchical regression analyses examined the relationship between self-efficacy and PCI, adjusting for depression and fatigue. Additional analyses tested self-efficacy as a mediator between depression, fatigue, and PCI. SETTING: Community. PARTICIPANTS: Community-dwelling individuals with MS (N=233; age range, 22-83y) were recruited from a larger longitudinal survey study of individuals with MS (N=562). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcome measures were the Applied Cognition-General Concerns and the Applied Cognition-Executive Function domains of the Quality of Life in Neurological Disorders (NeuroQoL) measures. RESULTS: Self-efficacy was significantly correlated with PCI at baseline (r=.40-.53) and 3 years later (r=.36-.44). In multivariate regression analyses, self-efficacy was a significant longitudinal predictor of PCI, both for general cognitive functioning (ß=.20, P<.01) and executive functioning (ß=.16, P<.05). Self-efficacy partially mediated the relationships between depression, fatigue, and PCI. CONCLUSIONS: Self-efficacy may influence how individuals with MS perceive their cognitive functioning over time. Interventions that target self-efficacy, particularly early in the disease course, may lead to improvements in PCI, as well as improvements in fatigue and depression.

Cognitive Impairment and Community Integration Outcomes in Individuals Living With Multiple Sclerosis.

OBJECTIVES: To determine the association between unique domains of cognitive impairment and community integration in individuals with multiple sclerosis (MS), and to determine the contributions of cognitive impairment to community integration beyond the influence of demographic and clinical variables. DESIGN: Cross-sectional analysis of objective neuropsychological assessment and self-report data. Data were collected during baseline assessment of a randomized, multisite controlled trial of ginkgo biloba for cognitive impairment in MS. Hierarchical regression analyses examined the association between subjective and objective measures of cognitive impairment and 3 domains of community integration, adjusting for relevant covariates. SETTING: Two Veterans Affairs medical center MS clinics. PARTICIPANTS: Adults (N=121; ages 24-65y) with a confirmed MS diagnosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcomes were scores on the Home Integration (CIQ-H), Social Integration (CIQ-S), and Productivity (CIQ-P) domains of the Community Integration Questionnaire (CIQ). RESULTS: Cognitive impairment was associated with lower scores on the CIQ-H and CIQ-S, but not the CIQ-P. Greater levels of subjective cognitive impairment were associated with lower scores on the CIQ-H and CIQ-S. Greater levels of objective cognitive impairment, specifically slower processing speed and poorer inhibitory control, were related to lower CIQ-S scores. Subjective and objective measures of cognitive impairment were significantly and independently associated with CIQ-S. CONCLUSIONS: Objective cognitive impairment may interfere with participation in social activities. Subjective cognitive impairment is also important to assess, because individuals who perceive themselves to be cognitively impaired may be less likely to participate in both home and social activities. Clinical interventions to enhance community integration in individuals with MS may benefit from addressing objective and subjective cognitive impairment by integrating cognitive rehabilitation approaches with self-efficacy-enhancing strategies.

Discrepancies between self-report and objective sleep outcomes are associated with cognitive impairment and fatigue in people with multiple sclerosis and insomnia.

OBJECTIVES: The primary aim of this study was to assess the degree to which discrepancies between self-reported and actigraphy-based measures of sleep are associated with specific demographic, disease characteristics, and clinical features in a sample of individuals with multiple sclerosis (MS) reporting clinically significant insomnia symptoms. METHODS: Participants were 90 community-based participants with MS and insomnia. Measures included the Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory-Fast Screen (BDI-FS), Modified Fatigue Impact Scale (MFIS), and MS Neuropsychological Screening Questionnaire (MSNQ), and wrist actigraphy-derived sleep parameters. Discrepancy scores were calculated by subtracting actigraphy-derived values from PSQI-derived values for sleep latency (SL), total sleep time (TST), and sleep efficiency (SE). RESULTS: Correlations between PSQI and actigraphy-derived values were weak. Significant discrepancies, with moderate-to-large effect sizes, were observed between PSQI and actigraphy for SL, TST, and SE, whereby the PSQI yielded longer SL, shorter TST, and less SE than actigraphy. MSNQ elevations correlated with greater PSQI-actigraphy discrepancies in SL and TST. MFIS elevations correlated with greater discrepancies in TST. Discrepancies were not significantly related to BDI-FS, gender, race, education level, or MS type. CONCLUSIONS: Results emphasize the importance of assessing fatigue with sleep, and when feasible, inclusion of both self-report and actigraphy measures.

Sleep disturbance and fatigue in multiple sclerosis: A systematic review and meta-analysis.

Sleep disturbance is common in people with multiple sclerosis and may worsen fatigue; however, the assessment of sleep-fatigue relationships varies across studies. To better understand sleep-fatigue relationships in this population, we conducted a systematic review and random effects meta-analyses for the associations between fatigue and 10 sleep variables: Sleep-disordered breathing, daytime sleepiness, sleep quality, insomnia, restless legs, number of awakenings, sleep efficiency, sleep latency, sleep duration, and wake after sleep onset. Of the 1062 studies screened, 46 met inclusion criteria and provided sufficient data for calculating Hedges' g. Study quality was assessed using the Newcastle-Ottawa Scale. Sample characteristics did not differ between the 10 analyses. Results indicated that sleep quality and insomnia (assessed via self-report or diagnostic criteria) were strongly associated with fatigue (all gs ≥ 0.80 and all ps < .001). In contrast, the number of awakenings and sleep duration (assessed objectively) were not significantly associated with fatigue. Remaining sleep variables yielded moderate, significant effects. Most effects did not vary based on study quality or sample demographics. Results highlight that insomnia and perceptions of poor sleep have a stronger link than objective sleep duration to fatigue in multiple sclerosis and may represent a more effective target for intervention.

Perioperative insomnia trajectories and functional outcomes after total knee arthroplasty.

ABSTRACT: Longitudinal total knee arthroplasty (TKA) studies indicate that a substantial percentage of patients continue to experience clinically significant pain and functional impairment after surgery. Insomnia has been associated with poorer surgical outcomes; however, previous work has largely focused on long-term postsurgical insomnia. This study builds on previous work by examining sleep and pain outcomes about perioperative insomnia trajectories. Insomnia symptoms (using the Insomnia Severity Index) during the acute perioperative period (2 weeks pre-TKA to 6 weeks post-TKA) were used to classify participants into perioperative insomnia trajectories: (1) No Insomnia (ISI < 8), (2) New Insomnia (baseline < 8; postoperative ≥ 8 or ≥6-point increase), (3) Improved Insomnia (baseline ≥ 8, postoperative < 8 or ≥6-point decrease), and (4) Persistent Insomnia (ISI ≥ 8). Insomnia, pain, and physical functioning were assessed in participants with knee osteoarthritis (n = 173; M age = 65 ± 8.3, 57.8% female) at 5 time points: 2 weeks pre-TKA, post-TKA: 6 weeks, 3 months, 6 months, and 12 months. Significant main effects were seen for insomnia trajectory and time, and trajectory-by-time interactions for postoperative insomnia, pain severity, and physical functioning ( P' s < 0.05). The Persistent Insomnia trajectory had the worst postoperative pain at all follow-ups and marked insomnia and physical functioning impairment post-TKA ( P' s < 0.05). The New Insomnia trajectory had notable long-term insomnia (6 weeks to 6 months) and acute (6 weeks) postoperative pain and physical functioning ( P' s < 0.05). Findings indicated a significant relationship between perioperative insomnia trajectory and postoperative outcomes. Results of this study suggest that targeting presurgical insomnia and preventing the development of acute postoperative insomnia may improve long-term postoperative outcomes, with an emphasis on persistent perioperative insomnia due to poorer associated outcomes.

Dialectical behavior therapy skills training for individuals with multiple sclerosis and their support partners: A pilot randomized controlled trial.

BACKGROUND: Symptoms of anxiety, depression, and emotion dysregulation are common among individuals with MS and their support partners. Dialectical behavior therapy (DBT) - a type of cognitive behavioral intervention - may be a promising treatment for individuals affected by MS. This pilot randomized controlled trial (RCT) assessed the effects and feasibility of remotely delivered DBT skills on anxiety and depression symptoms and emotion dysregulation in individuals with MS and their support partners. METHODS: This study featured a single-masked, two-arm, parallel group design. Twenty pairs of individuals with MS and their support partners (n = 40) were randomized to 12 weeks of DBT or facilitated peer support (FPS). Masked assessments were completed at weeks 0 (baseline), 13 (post-intervention), and 26 (follow-up). RESULTS: At post-intervention (primary endpoint), participants randomized to DBT exhibited significantly greater reductions in anxiety and depression symptoms compared to FPS (B = 4.45, p = .04, Cohen's d = 0.57). Secondary outcomes of emotion dysregulation and well-being favored the DBT group but did not reach statistical significance (ds = 0.51, ps = 0.07). Effects were not maintained at follow-up. Most (86%) individuals screened were eligible for the trial, and retention (70%) did not differ between study arms. CONCLUSIONS: This pilot RCT provides encouraging evidence that DBT skills is feasible and may improve depression, anxiety, and emotion dysregulation for individuals with MS and their support partners. Future research is needed to optimize maintenance of DBT skills, investigate mechanisms for these improvements, and replicate these promising effects in a fully powered trial.

Cognitive and Mood Profiles Among Patients With Stiff Person Syndrome Spectrum Disorders.

An emerging body of evidence suggests that changes in cognitive and emotional function are common aspects of stiff person spectrum disorders (SPSD). We sought to examine the pattern of cognitive impairment and psychiatric symptoms in SPSD. Methods: A retrospective review of medical records was conducted for patients seen at the Johns Hopkins Stiff Person Syndrome (SPS) center from 1997 to January 1st, 2020. Individuals who had received formal cognitive testing as part of routine clinical care for patient-reported cognitive changes were included. Demographics, prevalence of cognitive impairment, psychoactive medication use, and clinically significant psychiatric symptoms were described. Results: Out of 205 patients screened, 20 completed cognitive testing (75% female, mean age 47.4 years). The most common domains of impairment were verbal learning and recall memory (n = 14, 70%), verbal fluency (n = 10, 50%), processing speed (n = 8, 40%), and attention (n = 8, 40%). 9/11 patients assessed for depression reported clinically significant symptoms, and 4/9 patients assessed for anxiety reported clinically significant symptoms. Conclusions: Screening for cognitive impairment in SPSD should utilize testing that assesses verbal learning and recall, phonemic verbal fluency, attention, and processing speed. Moreover, it is important to evaluate for co-existing depression and anxiety symptoms, as these are common in SPSD.