Sleep and Military Leaders: Examining the Values, Beliefs, and Quality of Sleep and the Impact on Occupational Performance.

INTRODUCTION: Sleep deprivation is rampant within the military population, and insufficient sleep can lead to physical and mental health problems impacting soldier's readiness and deployability. Past research has shown the importance of leadership's role in subordinates' sleep health. Understanding the values, beliefs, and quality of military leader sleep is essential to the development of effective interventions to optimize occupational performance and overall sleep health. Therefore, the purpose of this study was to examine the military leaders' values, beliefs, and sleep quality and the impact on occupational performance. The authors aimed to (1) identify military leaders' sleep quality and beliefs; (2) explore the relationship between military leaders' sleep quality, beliefs and attitudes about sleep, and impact on occupational performance; and (3) examine the value leaders place on sleep for themselves and subordinates in relation to occupational performance. MATERIALS AND METHODS: This observational, mixed-methods study design recruited a convenience sample of 109 Army active duty medical service members currently serving in a leadership role. Participants completed an electronic survey to include general demographic information and three self-report measures: the Pittsburgh Quality of Sleep Index, the Dysfunctional Beliefs about Sleep, and the Functional Outcomes of Sleep Questionnaire. Eleven participants completed the semi-structured qualitative interview focusing on sleep values and the impacts on performance. Univariate and multivariate regressions were performed for statistical analysis of the quantitative survey data, whereas thematic analysis was used to analyze the qualitative interview data. This study was approved by the U.S. Army Medical Center of Excellence Institutional Review Board. RESULTS: Multivariate regression analysis demonstrated small-to-medium effect sizes (R2 = 0.355-0.559) for relationships between sleep quality, sleep beliefs, functional performance, and demographic variables. More specifically, military grade, position, use of alcohol, time in service, and gender were all found to contribute significantly to scores on the Pittsburgh Sleep Quality Index, the Dysfunctional Beliefs About Sleep Scale-16, and the Functional Outcomes of Sleep Questionnaire-10 (P < .05). Qualitative data resulted in three primary themes: (1) Poor sleep degrades performance, (2) sleep is a top priority, and (3) leaders have a responsibility for subordinates' sleep health. CONCLUSIONS: This sample of military leaders was found to perceive themselves as poor-quality sleepers despite demonstrating more functional attitudes and beliefs about sleep and reporting normal-to-mild impairments in daily functioning as a result of daytime sleepiness. Furthermore, findings suggest that leaders' sleep quality and beliefs stand to be further improved, whereas their sleep values need to be consistently demonstrated to subordinates. With a clearer understanding of military leaders' values, beliefs, and sleep quality, future research could focus on implementing and developing holistically based and individualized sleep interventions intended to optimize performance and sleep health.

Factors influencing final outcomes in patients with shoulder pain: A retrospective review.

STUDY DESIGN: Retrospective cohort. INTRODUCTION: Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians' prognosis for final outcomes. PURPOSE OF THE STUDY: The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain. METHODS: Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable. RESULTS: The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R2 = 0.538 (P < .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age. DISCUSSION: Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation. CONCLUSION: Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient's progress and indicate treatment effectiveness. LEVELS OF EVIDENCE: 4.

Roles of Occupational Therapists in Theater, Past and Present.

The impetus to deploy occupational therapy (OT) assets into theaters of operation lies in the occupational therapist's ability to evaluate the effect of physical and/or behavioral symptoms on functional performance and effectively develop individualized interventions. Occupational therapy utilization has been robust during 14 years of continuous deployments in Iraq and Afghanistan. Occupational therapy's indoctrinated role in combat is solely with the combat and operational stress control missions, however, the skills and capabilities of this profession have demonstrated efficacy in other specializations, including concussion care. The effectiveness of OT interventions is demonstrated with improved return to duty (RTD) rates for casualties suffering with combat and operational stress reactions where OT was a major component of a restoration and reconditioning program. As well, postconcussion RTD rates have been linked to the broad skill sets inherent in OT that allow casualties to remain in theater from the point of injury to complete recovery and RTD.

Specificity of the minimal clinically important difference of the quick Disabilities of the Arm Shoulder and Hand (QDASH) for distal upper extremity conditions.

Retrospective cohort design. The minimal clinically important difference (MCID) for the quick Disabilities of the Arm, Shoulder and Hand (QDASH) has been established using a pool of multiple conditions, and only exclusively for the shoulder. Understanding diagnoses-specific threshold change values can enhance the clinical decision-making process. Before and after QDASH scores for 406 participants with conditions of surgical distal radius fracture, non-surgical lateral epicondylitis, and surgical carpal tunnel release were obtained. The external anchor administered at each fourth visit was a 15-point global rating of change scale. The test-retest reliability of the QDASH was moderate for all diagnoses: intraclass correlation coefficient model 2, 1, for surgical distal radius = 0.71; non-surgical lateral epicondylitis = 0.69; and surgical carpal tunnel = 0.69. The minimum detectable change at the 90% confidence level was 25.28; 22.49; and 27.63 points respectively; and the MCID values were 25.8; 15.8 and 18.7, respectively. For these three distal upper extremity conditions, a QDASH MCID of 16-26 points could represent the estimate of change in score that is important to the patient and guide clinicians through the decision-making process.

Adherence of Individuals in Upper Extremity Rehabilitation: A Qualitative Study.

OBJECTIVE: To describe the rehabilitation experiences, expectations, and treatment adherence of patients receiving upper extremity (UE) rehabilitation who demonstrated discrepancy between functional gains and overall improvement. DESIGN: Qualitative (phenomenologic) interviews and analysis. SETTING: Outpatient UE rehabilitation. PARTICIPANTS: Patients with acute UE injuries (N=10). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Concerns related to UE rehabilitation patients demonstrating discrepancy between outcome measures. RESULTS: Five key themes emerged from the interviews of patients demonstrating discrepancy in their self-reported patient outcomes: (1) desire to return to normal, (2) initial anticipation of brief recovery, (3) trust of therapist, (4) cannot stop living, and (5) feelings of ambivalence. Challenges included living with the desire to move back into life. Multiple factors affected patient adherence: cost of treatment, patient-provider relation (difference between therapist and patient understanding on what is important for treatment), and patients expecting the treating therapists to be an expert and fix their problem. CONCLUSIONS: Patient adherence to UE rehabilitation presents many challenges. Patients view themselves as laypersons and seek the knowledge of a dedicated therapist who they trust to spend time with them to understand what they value as important and clarify their injury, collaboratively make goals, and explain the intervention to get them in essence, back into life, in the minimal required time. When categorized according to the World Health Organization's multidimensional adherence model, domains identified in this model include social and economic, health care team and system, condition-related, therapy-related, and patient-related dimensions. Assessing factors identified to improve efficiency and effectiveness of clinical management can enhance patient adherence.

Descriptive analysis of common functional limitations identified by patients with shoulder pain.

CONTEXT: Recent establishment of G-codes by the US government requires therapists to report function limitations at initial evaluation. Limited information exists specific to the most common limitations in patients with shoulder pain. OBJECTIVE: To describe the most commonly expressed shoulder limitations with activities and their severity/level of impairment from a patient's perspective on the initial evaluation. DESIGN: Descriptive. SETTING: Patients reporting pain with overhead activity and seeking medical attention from one orthopedic surgeon were recruited as part of a cohort study. PATIENTS: 176 with shoulder superior labral tear from anterior to posterior (SLAP), subacromial impingement, combined SLAP and rotator cuff, and nonspecific (female = 53, age = 41 ± 13 y; male = 123, age = 41 ± 12 y). INTERVENTIONS: Data were obtained on the initial visit from the Patient-Specific Functional Scale (PSFS) questionnaire. Three researchers extracted meaningful concepts from the PSFS and linked them to the International Classification of Functioning (ICF) categories according to established ICF linking rules. RESULTS: 176 participants yielded 765 meaningful concepts that were linked to the ICF with a 66% agreement between researchers before consensus. There were no differences between diagnoses. Of all patients, 88% reported functional limitations coded into meaningful concepts as represented by 10 ICF codes; 634 (83%) meaningful concepts were linked to the activities and participation domain while 129 (17%) were linked to the body function domain. Only 2 reported functional limitations that were considered nondefinable (nd). The overall average initial impairment score on the PSFS = 4 ± 2.5 out of 10 points. CONCLUSION: Meaningful concepts from the activities and participation domain were most commonly identified as functional limitations and were more prevalent than limitations from the body function domain. This information helps identify some of the most common limitations in patients with shoulder pain that therapists can use to efficiently document patient functional impairment.