Stretching is not essential for managing MS spasticity: A randomized controlled trial.

BACKGROUND: Clinical practice, expert opinion, and evidence-based guidelines recommend daily stretching as first-line treatment for multiple sclerosis (MS) spasticity, but this has not been evaluated by fully powered clinical trials. OBJECTIVE: To determine whether MS Spasticity: Take Control (STC), a guideline-based program of spasticity education and stretching exercises has different effects on the impact of spasticity than a control program of different spasticity education and range of motion (ROM) exercises. METHODS: Ambulatory people with self-reported MS spasticity were randomly assigned to STC or ROM, delivered in same duration, facilitator-led, group classes, face-to-face (F2F) initially and later virtually, due to coronavirus disease 2019 (COVID-19). Multiple Sclerosis Spasticity Scale (MSSS) scores were compared between groups at 1 (primary outcome) and 6 months after interventions. RESULTS: A total of 231 people enrolled. There was no significant difference in MSSS scores between STC and ROM at 1 month (mean difference = 0.28, 95% (confidence interval (CI)) = [-9.45 to 10.01], p = 0.955). There were significant group mean improvements in MSSS scores and most other outcomes at 1 and 6 months. CONCLUSION: Education with stretching exercises, the first-line recommended treatment for MS spasticity, and education with ROM exercises may both improve MS spasticity to a similar degree. This study debunks the belief that stretching is essential to managing MS spasticity.

A multisite randomized controlled trial of two group education programs for fatigue in multiple sclerosis: Very long term (5-6 year) follow-up at one site.

BACKGROUND: A multicomponent group MS fatigue self-management program reduced fatigue impact compared to a rigorous control 12 months after enrollment. OBJECTIVES: Assess and compare changes between groups in fatigue impact and behavior changes implemented 5-6 years after enrollment. METHODS: The Modified Fatigue Impact Scale (MFIS) and a behavior change questionnaire were administered 5-6 years after enrollment. RESULTS: There were no significant changes in mean MFIS scores within or between groups from baseline to 5-6 years later. Behavior changes were of similar frequency in both groups. CONCLUSION: Fatigue impact was stable and behavior changes were similar between groups 5-6 years after a fatigue self-management program.

Utility of mental health and sleep screening questionnaires for patients admitted to a seizure monitoring unit.

RATIONALE: Patients with seizure disorders have relatively high rates of comorbid psychological and sleep disorders. Because these can profoundly affect quality of life, early recognition and treatment are of potential benefit. As a quality improvement project, we evaluated the performance and utility of a set of mental health and sleep quality screening questionnaires in patients admitted to a VA seizure monitoring unit (SMU). METHODS: Questionnaires, including the Beck Depression Inventory-II (BDI-II), the post-traumatic stress disorder (PTSD) checklist (PCL), the Quality of Life in Epilepsy Inventory-31 (QOLIE-31), and the Pittsburgh Sleep Quality Index (PSQI), were administered to 100 patients admitted to the Portland VAMC SMU. Scored results were entered into the electronic medical record (EMR) within 72 h of hospital admission. We assessed how many patients exceeded questionnaire cutoff scores, and whether these patients had prior mental health or sleep diagnoses or evaluations within the six months preceding admission. Following hospital discharge, providers completed a survey regarding the utility of the questionnaire results. We also reviewed EMR documented mental health and sleep visits during the six months following the SMU admission. RESULTS: Forty-seven patients (47.5%) exceeded the cutoff score for the BDI-II, including 15 without an admission diagnosis of depression, and 14 who had not seen a mental health provider in the previous six months. Similarly, 33 patients (33.3%) exceeded the cutoff score for the PCL, including nine without a diagnosis of PTSD. Scores on the BDI-II and PCL were highly correlated with the QOLIE-31 total score (r = 0.7). Seventy patients (70.7%) exceeded the cutoff score for poor sleep quality, and 37 did not have a sleep disorder diagnosis. Providers indicated that the questionnaire results were moderately or very helpful in most cases and influenced discharge recommendations to patients and referring providers in more than 50% of cases. Discharge recommendations for mental health or sleep follow-up were associated with EMR documented consultations within the six months following SMU admission. CONCLUSIONS: The results suggest that a standard set of screening questionnaires can identify SMU patients at risk for mental health and sleep disorders, including patients not currently diagnosed or recently evaluated. Questionnaire results were perceived as helpful by providers and influenced discharge recommendations. Given that these disorders are treatable and have a major influence on health-related quality of life, the effort to collect and document this information is well justified.

Health-related quality of life in Veterans with epileptic and psychogenic nonepileptic seizures.

RATIONALE: Health-related quality of life (HRQoL) is compromised in civilians with epileptic seizures (ES) or psychogenic nonepileptic seizures (PNES). U.S. Veterans are a distinct patient group with regard to gender, age, and background. We studied HRQoL in Veterans and asked the following: (1) Is there a difference in HRQoL in Veterans with ES vs. PNES?; (2) What factors influence HRQoL in each group?; (3) What factors influenced the difference between seizure groups? METHODS: We studied consecutive Veterans entering the epilepsy monitoring units (EMUs) of three VA Epilepsy Centers of Excellence. Patients underwent continuous video-EEG monitoring. Seizure diagnoses followed established criteria. Health-related quality of life was measured with the Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual-IV (DSM IV), the posttraumatic stress disorder (PTSD) Checklist (PCL), the Beck Depression Inventory II (BDI-II), and the Minnesota Multiphasic Personality Inventory-2 Restructured form (MMPI-2RF). Between-group differences were tested with Wilcoxon tests. Nested regression analysis was used to evaluate the influence of demographic, social, military, seizure-related, and psychological factors on QOLIE-31 scores. RESULTS: The median QOLIE-31 total score was 14 points lower in Veterans with PNES vs. ES (p < 0.001; Cohen's d = 0.73). Within each seizure group, psychological factors accounted for ≥50% of the variance in QOLIE scores while combined demographic, social, and seizure-related factors accounted for 18% (group with ES) and 7% (PNES). Psychological measures, particularly PCL and the BDI-II scores, accounted for all of the difference in QOLIE-31 total scores between Veterans with ES and those with PNES. CONCLUSIONS: Health-related quality of life as measured by the QOLIE-31 is worse in Veterans with PNES as compared with those with ES. Psychological factors account for the most of the variance in QOLIE-31 scores regardless of seizure type and also account for the difference between groups with PNES and ES. Demographic, military, social, and seizure-related factors have minimal influence on HRQoL. These results in U.S. Veterans are similar to those found in civilians despite differences in patient age, gender, and background.

Psychiatric comorbidity and traumatic brain injury attribution in patients with psychogenic nonepileptic or epileptic seizures: A multicenter study of US veterans.

OBJECTIVE: To determine the frequency and severity of psychiatric disorders and attribution of seizures to traumatic brain injury (TBI) in veterans with verified psychogenic nonepileptic seizures (PNES) versus epileptic seizures (ES). METHODS: We studied 333 consecutive admissions to the monitoring units of three Veterans Administration epilepsy centers. All patients underwent continuous video-electroencephalographic recording to define definite PNES or ES. Evaluations included the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th edition, PTSD Checklist, Beck Depression Inventory II, and Patient Seizure Etiology Questionnaire. Interviews and questionnaires were completed prior to final seizure type diagnosis and patient debriefing. The primary outcome measure was a comparison of Axis I psychiatric diagnoses in patients diagnosed with PNES versus ES. RESULTS: A total of 81 patients were diagnosed with PNES, and 70 with ES. PTSD was the most frequent Axis I diagnosis in veterans with PNES (64%, vs 13% of those with ES; P < 0.001). Posttraumatic stress disorder (PTSD) was common regardless of deployment to a war theater or combat exposure. Mood, substance abuse, and anxiety disorders were also more common in the PNES group. TBI was cited as a likely cause of seizures by 47% of veterans with PNES versus 25% of those with ES (P = 0.01). PTSD and attribution of seizures to TBI were found in 30% of veterans with PNES versus 3% of those with ES (P < 0.001). SIGNIFICANCE: In veterans referred for inpatient seizure evaluation, PTSD was strongly associated with a diagnosis of PNES versus ES. The association of PNES with PTSD, attribution of seizures to TBI, or both, may prompt early consideration of PNES.

The facilitators and barriers associated with implementation of a patient-centered medical home in VHA.

BACKGROUND: The patient-centered medical home (PCMH) is a team-based, comprehensive model of primary care. When effectively implemented, PCMH is associated with higher patient satisfaction, lower staff burnout, and lower hospitalization for ambulatory care-sensitive conditions. However, less is known about what factors contribute to (or hinder) PCMH implementation. We explored the associations of specific facilitators and barriers reported by primary care employees with a previously validated, clinic-level measure of PCMH implementation, the Patient Aligned Care Team Implementation Progress Index (Pi(2)). METHODS: We used a 2012 survey of primary care employees in the Veterans Health Administration to perform cross-sectional, respondent-level multinomial regressions. The dependent variable was the Pi(2) categorized as high implementation (top decile, 54 clinics, 235 respondents), medium implementation (middle eight deciles, 547 clinics, 4537 respondents), and low implementation (lowest decile, 42 clinics, 297 respondents) among primary care clinics. The independent variables were ordinal survey items rating 19 barriers to patient-centered care and 10 facilitators of PCMH implementation. For facilitators, we explored clinic Pi(2) score decile both as a function of respondent-reported availability of facilitators and of rating of facilitator helpfulness. RESULTS: The availability of five facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile: teamlet huddles (OR = 3.91), measurement tools (OR = 3.47), regular team meetings (OR = 2.88), information systems (OR = 2.42), and disease registries (OR = 2.01). The helpfulness of four facilitators was associated with higher odds of a respondent's clinic's Pi(2) scores being in the highest versus lowest decile. Six barriers were associated with significantly higher odds of a respondent's clinic's Pi(2) scores being in the lowest versus highest decile, with the strongest associations for the difficulty recruiting and retaining providers (OR = 2.37) and non-provider clinicians (OR = 2.17). Results for medium versus low Pi(2) score clinics were similar, with fewer, smaller significant associations, all in the expected direction. CONCLUSIONS: A number of specific barriers and facilitators were associated with PCMH implementation, notably recruitment and retention of clinicians, team huddles, and local education. These findings can guide future research, and may help healthcare policy makers and leaders decide where to focus attention and limited resources.

Using a single item to measure burnout in primary care staff: a psychometric evaluation.

BACKGROUND: Burnout affects nearly half of all U.S. nurses and physicians, and has been linked to poor outcomes such as worse patient safety. The most common measure of burnout is the well-validated Maslach Burnout Inventory (MBI). However, the MBI is proprietary and carries licensing fees, posing challenges to routine or repeated assessment. OBJECTIVE: To compare a non-proprietary, single-item burnout measure to a single item from the MBI Emotional Exhaustion (MBI:EE) subscale that has been validated as a standalone burnout measure. DESIGN: Cross-sectional online survey. PARTICIPANTS: A sample of primary care providers (PCPs), registered nurses, clinical associates (e.g., licensed practical nurses (LPNs), medical technicians), and administrative clerks in the Veterans Health Administration surveyed in 2012. MAIN METHODS: We compared a validated one-item version of the MBI:EE and a non-proprietary single-item burnout measure used in the Physician Work Life Study. We calculated kappa statistics, sensitivity and specificity, positive predictive (PPV) and negative predictive values (NPV), and area under the receiver operator curve (AUC). We conducted analyses stratified by occupation to determine the stability of the correlation between the two measures. KEY RESULTS: We analyzed responses from 5,404 participants, including 1,769 providers and 1,380 registered nurses. The prevalence of burnout was 36.7% as measured on the single MBI:EE item and 38.5% as measured on the non-proprietary single-item measure. Relative to the MBI:EE, the non-proprietary single-item measure had a correlation of 0.79, sensitivity of 83.2%, specificity of 87.4%, and AUC of 0.93 (se = 0.004). Results were similar when stratified by respondent occupation. CONCLUSIONS: A non-proprietary single-item measure served as a reliable substitute for the MBI:EE across occupations. Because it is non-proprietary and easy to interpret, it has logistical advantages over the one-item MBI.

"We've not gotten even close to what we want to do": a qualitative study of early patient-centered medical home implementation.

BACKGROUND: The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees. OBJECTIVE: We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components. DESIGN: Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews. PARTICIPANTS: 241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington. APPROACH: Data coded and analyzed using conventional content analysis techniques. KEY RESULTS: Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics. CONCLUSIONS: PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.

Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees.

BACKGROUND: A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. Many protective factors from burnout are characteristics of patient-centered medical home (PCMH) models, though even positive organizational transformation is often stressful. The existing literature on the effects of PCMH on burnout is limited, with most findings based on small-scale demonstration projects with data collected only among physicians, and the results are mixed. OBJECTIVE: To determine if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in a national medical home transformation, the VA Patient Aligned Care Team (PACT). DESIGN: Web-based, cross-sectional survey and administrative data from May 2012. PARTICIPANTS: A total of 4,539 VA primary care personnel from 588 VA primary care clinics. MAIN MEASURES: The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. We also included administrative measures of workload and patient comorbidity. KEY RESULTS: Overall, 39 % of respondents reported burnout. Participatory decision making (OR 0.65, 95 % CI 0.57, 0.74) and having a fully staffed PACT (OR 0.79, 95 % CI 0.68, 0.93) were associated with lower burnout, while being assigned to a PACT (OR 1.46, 95 % CI 1.11, 1.93), spending time on work someone with less training could do (OR 1.29, 95 % CI 1.07, 1.57) and a stressful, fast-moving work environment (OR 4.33, 95 % CI 3.78, 4.96) were associated with higher burnout. Longer tenure and occupation were also correlated with burnout. CONCLUSIONS: Lower burnout may be achieved by medical home models that are appropriately staffed, emphasize participatory decision making, and increase the proportion of time team members spend working to the top of their competency level.

Association of medical home team-based care functions and perceived improvements in patient-centered care at VHA primary care clinics.

INTRODUCTION: Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. MATERIAL AND METHODS: We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. RESULTS: 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (ß=32, P<0.0001) and history of change in the clinic (ß=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (ß=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (ß=-0.19, P=0.001). CONCLUSIONS: Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. IMPLICATIONS: Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics.

Abdominal bloating in employed adults: prevalence, risk factors, and association with other bowel disorders.

UNLABELLED: BACKGROUND Bloating is common, but its significance as a marker of underlying disease has not been defined. AND AIMS: We report on risk factors for bloating, its relationship to physical activity and quality of life (QOL), and its predictive value for functional bowel disorders. METHODS: This is a cross-sectional population-based study of 1,069 employees of the Veterans Affairs Black Hills Health Care System. The validated Bowel Disease Questionnaire was used to identify subjects with abdominal bloating and other bowel disorders. The association of bloating with QOL was assessed using the SF36 (Short-Form 36) questionnaire. Physical activity was assessed using the modified Baecke questionnaire. RESULTS: The response rate was 72% (723 of 1,069). Bloating was reported by 21% of all subjects (95% confidence interval [CI] 17.7-23.7), 64% with irritable bowel syndrome (IBS), 35% with non-IBS constipation, 23% with non-IBS diarrhea, and 42% with dyspepsia. Functional bloating (i.e., bloating in the absence of other bowel disorders) was reported by 7% of subjects (95% CI 5.2-9.0). Of those with bloating, 28% had IBS, 25% non-IBS constipation, 8% non-IBS diarrhea, and 30% dyspepsia. The positive and negative predictive values of bloating in the diagnosis of functional bowel disorder were 66% and 87%, respectively. The only risk factors were smoking and high-dose aspirin. Bloating was not associated with physical activity. QOL on all subscales of SF36 was lower in subjects with bloating than those without bloating. CONCLUSIONS: Bloating is a common symptom in otherwise healthy adults, and is often associated with but not predictive of functional bowel disorders. Smoking and high-dose aspirin are associated with bloating while physical activity is not.

Is constipation associated with decreased physical activity in normally active subjects?

BACKGROUND: The effectiveness of physical activity in the management of constipation remains controversial. We examined the associations among physical activity, constipation, and quality of life (QoL) in a population of employed adults to determine whether the risk of constipation is related to physical activity. METHODS: A total of 1,069 employees (age range 24-77) of the Veterans Affairs (VA) Black Hills Health Care System were mailed validated questionnaires (response rate 72%), inquiring about bowel habits, QoL (SF 36), and physical activity (modified Baecke questionnaire). Constipation was defined using the Rome I criteria. RESULTS: One hundred and forty (19.4%, 95% CI 16.2-22.4) employees reported constipation. The average total physical activity and all subscales of physical activity were not significantly different in subjects with and without constipation (all p > or = 0.2). Subjects with constipation had lower QoL scores than subjects without constipation, and physical activity was positively correlated with physical functioning and health perception. CONCLUSION: Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved QoL. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.

Chronic fatigue in a population-based study of Gulf War veterans.

Fatigue has been associated with illness in veterans of the Gulf War; however, few studies have confirmed self-reported fatigue by using clinical evaluation, and symptomatic veterans have not been evaluated with established criteria for Chronic Fatigue Syndrome (CFS). The authors describe the frequency and clinical characteristics of CFS in a sample of veterans residing in the northwestern United States. The sample was selected randomly from U.S. Department of Defense databases of troops deployed to southwest Asia during the Gulf War. The selected individuals were invited to participate in a clinical case-control study of unexplained illness. Of 799 survey respondents eligible for clinical evaluation, 178 had fatigue symptoms. Of the 130 veterans who were evaluated clinically, 103 had unexplained fatigue, and 44 veterans met the 1994 U.S. Centers for Disease Control criteria for CFS. In this population, the authors estimated a minimum prevalence of any unexplained fatigue to be 5.1%, and of CFS to be 2.2%. The estimated prevalence was greater among females than among males. Cases were similar to healthy controls, as determined by laboratory tests and physical findings. In comparison to several clinical studies of CFS patients, the authors of this study found a lower proportion of veterans who reported a sudden onset of symptoms (19%) vs. a gradual onset (50%). Although it has previously been suggested that veterans of the Gulf War suffer from higher rates of chronic fatigue than the general population, the study results described herein--on the basis of clinical examination of a population-based sample of veterans-actually indicate that an increased rate may indeed exist. Gulf War veterans with unexplained fatigue should be encouraged to seek treatment so that the impact of these symptoms on overall quality of life can be reduced.

Obesity and upper body fat distribution in Mexican American children from families with a diabetic proband.

Upper and centralized body fat distribution is associated with non-insulin dependent diabetes mellitus (NIDDM). Few studies have focused on anthropometric characteristics of preadults from families in which there is a diabetic (NIDDM) proband. This study explores the prevalence of upper and centralized body fatness in Mexican American children from the Diabetes Alert study (1981-1983) in Starr County, Texas. Anthropometric data on 165 males and 224 females 9-19 years include measures of adiposity such as skinfold thicknesses and the body mass index (BMI), a measure of overweight. They show rates of obesity two to three times that of White children of comparable age and sex from National Health Surveys. In comparison with U.S. White subjects, Mexican American adults are shorter, have more adiposity and arm muscle mass and have sitting heights and body breadths at the mean of these dimensions for the U.S. POPULATION: Children from Diabetes Alert families show only marginal excess of severe obesity (> 95th percentile of BMI) when compared to the general population of children surveyed in Starr County schools. Girls from these families, but not boys, have excess fatness in the BMI compared to Mexican American children from the Hispanic Health and Nutrition Examination Survey (HHANES); suprailiac skinfold thicknesses are also greater in children of the Diabetes Alert study than in HHANES children. From 1972 through 1982, Mexican American children in South Texas showed an increase in average stature, weight, and the BMI. These data together suggest that excessive obesity exists and may be increasing in children in populations at risk for NIDDM. The prevention of NIDDM in the Mexican American population may be more effective if educational and promotional interventions include the school aged population. © 1993 Wiley-Liss, Inc.