Creative Arts Therapies in Rehabilitation.

Appreciation for the utility of creative arts therapy in rehabilitation is on the rise. The limitations of conventional approaches to address posttraumatic stress disorder and co-occurring traumatic brain injury is spurring the development and increased use of creative arts therapies, especially in US military health care systems. However, emerging applications of creative arts therapies in rehabilitation extend well beyond posttraumatic stress disorder/traumatic brain injury and military populations to span the continuum of care, from the intensive care unit, postoperative recovery unit, acute inpatient medical and surgical wards, outpatient clinics, and home health, as well as in traditional long-term care and psychiatric settings. Critical steps to more fully integrating creative arts therapies in rehabilitation include the following: (1) incorporation of education about creative arts therapies into the curricula across rehabilitation disciplines; (2) alteration of national and state policies to promote greater inclusion of creative arts therapies as reimbursable treatments for a wide array of clinical diagnoses and conditions; and (3) significant expansion of creative arts therapies' evidence base. This can be achieved by increasing funding levels to encourage rigorously designed and controlled studies to determine the efficacy, populations, diagnoses and conditions, cofactors, and the mechanisms of action of creative arts therapies. The time has come for a concentrated effort from the community of rehabilitation professional associations, advocacy organizations, and practitioners to promote the advancement and inclusion of creative arts therapies into appropriate clinical settings to optimize outcomes for patients.

Health services and rehabilitation for active duty service members and veterans with mild TBI.

OBJECTIVE: We review health services and reintegration practices that contribute to the rehabilitation of US active duty service members (ADSMs) and Veterans who experienced traumatic brain injury (TBI), especially mild TBI (mTBI), as discussed at the 2015 Department of Veterans Affairs (VA) TBI State-of-the-Art (SOTA) Conference. METHODOLOGY: We reviewed the state-of-the-art at the time of the previous 2008 TBI SOTA Conference, advances in the field since then, and future directions to address gaps in knowledge. MAIN RESULTS: We reviewed: (1) mTBI and its comorbid conditions documented in ADSMs and Veterans, and recognized the need for additional healthcare utilization, health cost and quality of care studies; (2) VA vocational rehabilitation programmes and the effectiveness of supported employment for helping those with workplace difficulties; (3) the application of technology to assist in TBI rehabilitation, including mobile device applications for self-management, videoconferencing with providers, and virtual reality to help with behavioural and cognitive challenges, and (4) Department of Defense (DoD)-VA partnerships on identification, evaluation and dissemination of TBI best practices. CONCLUSIONS: There have been significant advances in TBI rehabilitation, but multiple areas across the DoD and VA care continuum need further exploration and development to meet the needs of ADSMs and Veterans.

Exploring the evocative qualities of masks' visual imagery and their associations with adversity and trauma.

Introduction: Studies suggest a relationship between the emotional evocativeness of visual imagery and viewer responses, however, there is limited understanding of these associations, especially as they relate to viewers' personal experiences of adversities. Methods: In this exploratory study, we examined the relationship between the visual content of mask images and viewers' responses. In an online survey 699 participants (of n = 1,010 total initial participants) rated 98 masks based on valence, arousal, and personal relevance and completed the Life Events Checklist. The masks included those created by service members (SMs) with traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD), depicting physical, psychological, and moral injuries and matched neutral masks created by creative arts therapists and arts in health scholars. Findings: The findings indicated that responses to mask image content (traumatic versus neutral) were associated with viewers' personal history of adversity and trauma. Specifically, images representing injury/trauma provoked stronger reactions on valence and arousal than neutral images. Moreover, participants with personal histories of trauma had heightened emotional responses to distressing imagery. Discussion: These findings have implications for art therapists as well as for clinical and general populations in that these results highlight the potential impact of distressing imagery particularly for individuals with personal histories of experiencing or witnessing traumatic events.

Delayed diagnosis of intracerebral foreign body from the Vietnam War.

We report on a 22-year-old infantryman who sustained a right frontal wound to his head. He was treated and returned to duty immediately. During a computed tomography scan, 38 years after the incident, a metallic foreign body and disruption of the brain consistent with a projectile track were discovered in his brain. In this report, we review similar cases of delayed discovery of unsuspected foreign bodies and the probable nature of the wound.

Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial.

BACKGROUND: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. OBJECTIVE: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. METHODS: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. RESULTS: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. CONCLUSIONS: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21799.

Cost effectiveness of a telerehabilitation program to support chronically ill and disabled elders in their homes.

Chronic illnesses account for approximately 75% of all healthcare costs in the United States today, resulting in functional limitations and loss of independence, as well as increased medical expenditures. The elderly population is at a higher risk for developing chronic conditions, increasing their risk for disabilities. Given the rapid growth of the aging population, and the chronic illnesses, disabilities, and loss of functional independence endemic to elders, novel methods of rehabilitation and care management are urgently needed. Telehealth models that combine care coordination with communications technology offer a means for managing chronic illnesses, thereby decreasing healthcare costs. We examined the effects of a Veterans Administration (VA) telerehabilitation program (Low Activities of Daily Living [ADL] Monitoring Program-LAMP) on healthcare costs. LAMP is based on a rehabilitative model of care. LAMP patients received adaptive equipment and environmental modifications, which focused on self-care and safety within the home. LAMP Care Coordinators remotely monitored their patient's vital signs and provided education and self-management strategies for decreasing the effects of chronic illnesses and functional decline. The matched comparison group (MCG) received standard VA care. Healthcare costs 12 months preenrollment and 12 months post-enrollment were examined through a difference-in-differences multivariable model. Using actual costs totaled for these analyses, no significant differences were detected in post-enrollment costs between LAMP and the MCG. For LAMP patients, the provision of adaptive equipment and environmental modifications, plus intensive in-home monitoring of patients, led to increases in clinic visits post-intervention with decreases in hospital and nursing home stays.

V-Mart, a Virtual Reality Grocery Store: A Focus Group Study of a Promising Intervention for Mild Traumatic Brain Injury and Posttraumatic Stress Disorder.

OBJECTIVE: This study examined the potential usability, relevance, and acceptability of V-Mart, a virtual reality grocery store as an assessment and intervention tool for veterans with mild traumatic brain injury. DESIGN: Six focus groups were conducted for a 2-yr period to assess perceptions from the following three key stakeholders: therapists, veterans with neither mild traumatic brain injury nor posttraumatic stress disorder, and veterans with mild traumatic brain injury with or without posttraumatic stress disorder (mild traumatic brain injury/posttraumatic stress disorder). The System Usability Scale was applied as an objective measure of usability. Transcripts from the six focus groups were subjected to thematic analyses using the constant, comparative method. RESULTS: The focus groups indicated that V-Mart was perceived as highly usable, relevant, and acceptable. Early technical problems were resolved satisfactorily. Therapists indicated that they would use an application such as V-Mart if it were available. The veterans with neither mild traumatic brain injury nor posttraumatic stress disorder felt that it was realistic and likely to be useful, as did the veterans with mild traumatic brain injury/posttraumatic stress disorder. The System Usability Scale mean follow-up scores ranged from 71.4 to 86.0, surpassing the threshold for acceptable usability in health care settings. CONCLUSIONS: Focus group and System Usability Scale data indicate that the V-Mart has great potential as an assessment tool and intervention for veterans with mild traumatic brain injury/posttraumatic stress disorder. Further development and clinical trials are warranted.

Enhancing health and independent living for veterans with disabilities by leveraging community-based resources.

The number of US veterans with disabilities has increased in recent years as service members have returned home with extensive injuries and veterans from previous wars acquire functional limitations as a consequence of aging with chronic diseases. Veterans with severe disabilities need assistance and support to maintain independence at home and to avoid institutionalization. The US Department of Veterans Affairs (VA) strives to network with community organizations to achieve the best possible outcomes for veterans. Key community resources in the US for individuals with disabilities are Centers for Independent Living (CILs) that provide a wide range of services, promoting independent living and well-being for people across disabilities. The widespread availability and services of CILs nationwide suggest their potential as a community-based resource for veterans, particularly for those with limited access to VA care. In this article, we discuss long-term needs of veterans with disabilities, efforts to address veterans' rehabilitation needs at the VA and opportunities for leveraging the strengths of community-based organizations for veterans. More research is warranted to investigate CIL services and potential for CIL-VA partnerships.

Effects of physical therapy delivery via home video telerehabilitation on functional and health-related quality of life outcomes.

This study examined functional outcomes, health-related quality of life (HRQoL), and satisfaction in a group of Veterans who received physical therapy via an in-home video telerehabilitation program, the Rural Veterans TeleRehabilitation Initiative (RVTRI). A retrospective, pre-post study design was used. Measures obtained from 26 Veterans who received physical therapy in the RVTRI program between February 22, 2010, and April 1, 2011, were analyzed. Outcomes were the Functional Independence Measure (FIM); Quick Disabilities of the Arm, Shoulder, and Hand measure; Montreal Cognitive Assessment (MoCA); and the 2-minute walk test (2MWT). HRQoL was assessed using the Veterans RAND 12-Item Health Survey (VR-12), and program satisfaction was evaluated using a telehealth satisfaction scale. Average length of participation was 99.2 +/- 43.3 d and Veterans, on average, received 15.2 +/- 6.0 therapeutic sessions. Significant improvement was shown in the participants' FIM (p < 0.001, r = 0.63), MoCA (p = 0.01, r = 0.44), 2MWT (p = 0.006, r = 0.73), and VR-12 (p = 0.02, r = 0.42). All Veterans reported satisfaction with their telerehabilitation experiences. Those enrolled in the RVTRI program avoided an average of 2,774.7 +/- 3,197.4 travel miles, 46.3 +/- 53.3 hr of driving time, and $1,151.50 +/- $1,326.90 in travel reimbursement. RVTRI provided an effective real-time, home-based, physical therapy.

Exploratory pilot study of driving perceptions among OIF/OEF Veterans with mTBI and PTSD.

Veterans of Iraq and Afghanistan may experience driving-related challenges postdeployment, including more at-fault crashes. Causes may include defensive driving tactics learned for combat zones and consequences of traumatic brain injuries (TBIs) and posttraumatic stress disorder (PTSD). Tailoring driver interventions to meet Veterans' needs requires an understanding of their driving perceptions. We explored the driving perceptions of five combat Veterans (4 men, 1 woman) with mild TBI and PTSD using grounded theory methods. Veterans participated in single, semistructured interviews during a comprehensive driving evaluation. Interviews were digitally recorded, transcribed verbatim, verified, and imported into NVivo 8 software for coding and analysis. Veterans were insightful about driving and identified specific environmental triggers for anxious driving, speeding, and road rage. Veterans used strategies to moderate driving behaviors, but continued to drive aggressively. Themes were used to develop a conceptual framework of driving postdeployment, laying the foundation for intervention studies.

Wheelchair propulsion biomechanics and wheelers' quality of life: an exploratory review.

PURPOSE. To provide an overview of associations between wheelchair propulsion biomechanics for both everyday and racing wheelchairs, wheeling-related upper limb injuries, and quality of life of manual wheelchair users through a synthesis of the available information. METHODS. A search of publications was carried out in PubMed and SportsDiscus databases. Studies on wheelchair propulsion biomechanics, upper limb injuries associated with wheelchair propulsion and quality of life of wheelchair users were identified. Relevant articles cited in identified articles but not cited in PubMed or SportsDiscus were also included. RESULTS. Wheelchair sports participation has positive impact on quality of life and research in racing wheelchair biomechanics can indirectly promote the visibility of wheelchair sports. The impact of pushrim-activated power-assisted wheelchairs (a hybrid between manual and battery-powered wheelchairs) and geared manual wheels on wheelers' everyday life were discussed. CONCLUSIONS. The study of wheelchair propulsion biomechanics focuses on how a wheelchair user imparts power to the wheels to achieve mobility and the accumulated knowledge can help to improve wheelchair users' mobility, reduce physical stress associated with wheelchair propulsion, and as a result, enhance quality of life.

Use of power assist wheels results in increased distance traveled compared with conventional manual wheeling.

OBJECTIVE: To evaluate the impact of power assist wheels on the distance traveled by manual wheelchair users and analyze potential cofactors in the magnitude of response and to test the hypothesis that wheelers would travel significantly further with power assist wheels. DESIGN: A 16-wk A (Preintervention)-B (Intervention)-A (Postintervention) repeated measures design. Seven women and 13 men (age, 43 +/- 15 yrs) full-time wheelers participated. During the pre- and postintervention phases (4 wks each), participants used their own unaltered manual wheelchairs. During the 8-wk intervention phase, the manual wheels were replaced with power assist wheels. Daily distance was measured with bicycle-style odometers. A composite score of laboratory wheelchair tasks was used to classify wheelchair performance. Mixed model repeated measures analysis of variance analyzed changes across phases of the trial. A post hoc analysis tabulated the amount of days wheelers exceeded their individual daily averages in each phase by two SDs. RESULTS: Wheelers traveled significantly greater distances during the intervention phase compared with pre- or postintervention phases regardless of baseline wheelchair performance. Wheelers who demonstrated higher baseline wheelchair performance traveled lesser average distances in the first 2 wks after receiving power assist wheels than in the subsequent 6 wks. Wheelers exceeded their individual daily averages per phase on a significantly greater number of days during the intervention phase. CONCLUSIONS: Power assist wheels enabled wheelers to travel farther and to travel beyond their usual distances on more days. Further studies may be strengthened by taking into account the 2-wk "adjustment phase" for power assist wheels.

Wheelchair users' perceptions of and experiences with power assist wheels.

OBJECTIVE: To assess wheelchair users' perceptions of and experiences with power assist wheels using qualitative interview methods. DESIGN: Qualitative evaluations were conducted in a laboratory setting with a focus on users' experiences using power assist wheel in their naturalistic environments. Participants consisted of seven women and 13 men (M(age) = 42.75, SD = 14.68) that included one African American, one Hispanic, 17 whites, and one individual from Zambia. Qualitative interviews were conducted before, during, and after use of a power assist wheel. Main outcome measures included the wheelchair users' evaluations and experiences related to the use of power assist wheels. RESULTS: The primary evaluations included wheeling on challenging terrains, performance of novel activities, social/family aspects, fatigue, and pain. These descriptions indicated that most participants perceived positive experiences with the power assist wheels, including access to new and different activities. Secondary evaluations indicated that the unit was cumbersome and prohibitive for some participants because of difficulties with transport in and out of a vehicle and battery life. Most participants felt that power assist wheels provided more independence and social opportunities. CONCLUSIONS: The power assist wheel seems to offer physical and social benefits for most wheelers. Clinicians should consider users' home environment and overall life circumstances before prescribing.

Methodological challenges confronting researchers of wheeled mobility aids and other assistive technologies.

PURPOSE: To identify gaps in assistive technology (AT) research and solutions, with a focus on wheeled mobility. METHODS: Literature review. RESULTS: AT researchers have identified a need to move beyond determining whether a device works well in the laboratory or is perceived favorably by users. The vital next step in AT research is to determine the effects of AT when used for day-to-day activities by typical consumers. Four challenges affect AT research on everyday mobility: (1) the heterogeneity of the population using AT, the environments in which AT is used, and the devices themselves; (2) the dependency of empirical research on objective data for valid causal inference; (3) the need for detailed information to capture the interaction between the person, the device, and the environment in which it is used; and (4) the extent to which success or failure of AT is dependent on the personal perspectives of the individual using the device. These challenges are being addressed by AT researchers through use of new measures, novel data collection methods, and by linking quantitative with qualitative data. CONCLUSIONS: AT researchers are adapting traditional research designs and analytic methods to examine that effects of AT on everyday life.