Rasch analysis of alcohol abuse and dependence diagnostic criteria in persons with spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVE: The objective of the study is to examine whether alcohol use disorders should be conceptualized categorically as abuse and dependence as in the 'Diagnostic and Statistical Manual of Mental Disorders' 4th edition or on a single continuum with mild to severe category ratings as in the 'Diagnostic and Statistical Manual of Mental Disorders' 5th edition in people with spinal cord injury (SCI). SETTING: United States of America. METHODS: Data from 379 individuals who sustained SCI either traumatically or non-traumatically after the age of 18 and were at least 1 year post injury. Rasch analyses used the alcohol abuse and dependence modules of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders Non-patient Edition (SCID-I/NP). RESULTS: Fifty-seven percent (n=166) of the entire sample endorsed criteria for alcohol abuse, and 25% (n=65) endorsed criteria for alcohol dependence. Fit values were generally acceptable except for one item (for example, alcohol abuse criterion 2), suggesting that the items fit the expectation of unidimensionality. Examination of the principal components analysis did not provide support for unidimensionality. The item-person map illustrates poor targeting of items. CONCLUSIONS: Alcohol abuse and dependence criterion appear to reflect a unidimensional construct, a finding that supports a single latent construct or factor consistent with the DSM-5 diagnostic model.

Are intensive data collection methods in pain research feasible in those with physical disability? A study in persons with chronic pain and spinal cord injury.

PURPOSE: Intensive repeated measures data collection procedures, such as ecological momentary assessment (EMA) and end-of-day (EOD) diaries, are becoming more prominent in pain research. Existing data on the feasibility of such methods is encouraging; however, almost nothing is known about feasibility in clinical populations with significant physical disabilities. Research methodology feasibility is crucial to the inclusion of individuals with physical disability in pain research given the high prevalence and impact of pain in these populations. The aim of this study was to examine study compliance, protocol acceptability, and reactivity of intensive data collection methods in adults with chronic pain and spinal cord injury (SCI). METHODS: Secondary analysis of data from a 7-day EMA and EOD diary study in a sample of 131 community dwelling adults with SCI. RESULTS: Results showed rates of missing data ranged from 18.4 to 22.8% across measures. Participant compliance was related to time of day/presence of audible prompts, mobility aid use, race, and baseline levels of pain and pain interference, with more missing data at wake and bedtimes/no prompts, and for those who used hand-held mobility devices, identified as black/African American, and/or reported higher baseline pain and pain interference. Participants rated the study methodology as generally highly acceptable and expressed willingness to participate in similar studies of much longer duration. There was no evidence of reactivity, defined as temporal shifts in pain or pain interference ratings. CONCLUSIONS: Overall, intensive pain data collection is feasible in persons with SCI with no evidence that the methodology impacts pain intensity or pain interference ratings.

Predictors of well-being among significant others of persons with multiple sclerosis.

OBJECTIVE: To examine patient and significant other characteristics as predictors of significant other well-being. METHODS: A total of 74 persons with multiple sclerosis (MS) and their significant others participated. Executive functioning was measured using neuropsychological tests. Awareness of cognitive deficit was measured as the discrepancy between the patient's reports of their abilities and objective test results. Awareness of functional deficit was measured as the discrepancy between the patient's and significant other's reports of the patient's functional abilities. Patient neurobehavioral disturbance was measured using a significant-other rated questionnaire. Significant other perceived social support and well-being (ie, psychological distress, life satisfaction, and general health status) were assessed using questionnaires filled out by the significant other. RESULTS: Executive dysfunction, neurobehavioral disturbance, and lack of awareness of functional deficits in patients were associated with poor well-being outcomes; whereas, lack of awareness of cognitive deficits was only weakly related to well-being. Social support was associated with positive well-being outcomes. CONCLUSIONS: Diminished insight regarding functional limitations may increase significant others' supervisory burden as patients attempt activities independently, whereas lack of awareness of cognitive deficits may not be directly associated with behavior-relevant impairments that significant others find distressing. Social support appears to be a powerful aid in diffusing the distress among significant others of MS patients.

Emotional and behavioral adjustment after traumatic brain injury.

OBJECTIVES: To examine emotional and behavioral adjustment and recovery over 1 year after traumatic brain injury (TBI), and to determine whether the difficulties, if present, are due to neurologic insult. DESIGN: Longitudinal evaluation of adjustment from 1 month to 1 year after injury. SETTING: Level I trauma center at a university hospital. PATIENTS: One hundred fifty-seven consecutively hospitalized adults with TBI and 125 trauma controls with other system injuries evaluated at 1 and 12 months after injury. MAIN OUTCOME MEASURES: Katz Adjustment Scale (KAS). RESULTS: The TBI group at 1 year follow-up demonstrated significant emotional and behavioral maladjustment, but such difficulties did not appear to be mediated by the brain injury, since the KAS scores for the TBI and trauma control groups were not significantly different. Those with moderate TBI reported greater difficulties than those with mild or severe injuries. Changes in adjustment over 1 year were common for both groups. Within the TBI group there was differential recovery: improvement in cognitive clarity, dysphoric mood, and emotional stability, but increased difficulties with anger management, antisocial behaviors, and self-monitoring. CONCLUSIONS: These results raise questions about commonly held beliefs that those with mild TBI report greater distress, and clarify some misconceptions regarding change in emotional and behavioral functioning over time.

Measures of executive functioning as predictors of functional ability and social integration in a rehabilitation sample.

OBJECTIVE: To examine the utility of executive function tests in predicting rehabilitation outcome. DESIGN: A prospective, descriptive study of the value of neuropsychologic and motor functioning measures in the prediction of functional outcome 6 months after acute rehabilitation. SETTING: A Midwestern, urban, university-affiliated rehabilitation hospital. PATIENTS: Ninety consecutive admissions to traumatic brain injury, orthopedic, and spinal cord injury units. Age of the participants ranged from 17 to 73. MAIN OUTCOME MEASURES: Community Integration Questionnaire (CIQ), Disability Rating Scale (DRS), SF-36 Health Survey. RESULTS: Canonical correlation analyses indicated that measures of executive functioning and verbal memory were strongly related to measures of functional outcome 6 months after rehabilitation, as measured by the DRS and the CIQ. In contrast, perceived health status as measured by the SF-36 was highly related to estimated premorbid IQ and modestly related to visuospatial impairment. CONCLUSIONS: Executive functioning, verbal memory, and estimated premorbid intelligence predict functional dependence after discharge from rehabilitation beyond information regarding basic sensory and motor skills. Moreover, there is a dissociation between measures of functional outcome, such that objective and behaviorally oriented measures of disability (CIQ and DRS) are strongly related to each other; however, they are not related to perceptions of general health status (SF-36).

Executive functioning and predictors of falls in the rehabilitation setting.

OBJECTIVE: To examine the incremental utility of executive function tests in the prediction of inpatient falls. DESIGN: Evaluation of neuropsychologic and medical risk factors for fall was completed at admission. Inpatient falls were tabulated following discharge. SETTING: A freestanding, urban rehabilitation hospital. PATIENTS: Ninety consecutive admissions to traumatic brain injury, orthopedic, and spinal cord injury wards. Age of the participants ranged from 17 to 73 years old. MAIN OUTCOME MEASURE: Incident reports of inpatient falls. RESULTS: Standard multiple regression analyses indicated that measures of executive functioning sensitive to self-monitoring accounted for unique variance in falls beyond that explained by age and functional motor ability as assessed by the Functional Independence Measure. Visuospatial functioning, although not directly related to falls, was a significant predictor in combination with measures of executive functioning. Together, these variables accounted for 30.3% of the variance in inpatient falls (multiple r = .55; p < .001). CONCLUSION: The findings suggest that the influence of motor and sensory impairments on falls are moderated, in part, by executive functioning. Patients with intact executive functioning are less likely to act in ways that could result in a fall; thus, aggressive fall prevention measures may be unnecessary. In contrast, executive dysfunction may signal the need for intervention, even among patients whose profiles are unremarkable with regard to traditional risk factors for fall.

Physical, psychological, and social outcomes in geriatric rehabilitation patients.

OBJECTIVE: Previous research studies that addressed the relationship between age and functional outcome had limited generalizability because of small sample size, lack of an urban population, and limited variables that do not allow for a complete investigation of social, cognitive, psychological, and medical factors in geriatric rehabilitation. The present study attempted to assess the relationship between decade of geriatric life (60s, 70s, 80s, and 90+) and functional outcome. DESIGN: Survey study of geriatric cohorts. SETTING: Inpatient university-affiliated rehabilitation hospital. PATIENTS: 812 urban geriatric rehabilitation patients divided into four groups based on decade of life. MAIN OUTCOME MEASURES: Index of comorbid disease, principal diagnoses, Functional Independence Measure, Mattis Dementia Rating Scale, Geriatric Depression Scale, CAGE alcohol questionnaire, and residential status at admittance and discharge. RESULTS: Although there were no significant demographic differences between groups (apart from age), there were differences in functional outcome suggesting that the younger old (60s and 70s) and the older old (80s and 90+) patients may represent two different rehabilitation groups. CONCLUSIONS: The younger old patients showed significantly higher alcohol abuse and comorbid physical disease, while the older-old patients demonstrated significantly poorer cognitive skills and more dependent social status on discharge from the rehabilitation facility. Despite the younger group's physical problems and alcohol use, they demonstrated better physical recovery. Implications for working with these two groups of urban geriatric patients in a rehabilitation setting are discussed.