Development and validation of a method to screen for co-morbid depression by non-behavioral health practitioners treating musculoskeletal pain.

BACKGROUND: Although diagnosis and treatment of depressive illness is outside the scope of practice for non-behavioral health practitioners such as occupational therapists, physical therapists, kinesiotherapists, and chiropractors, it frequently is comorbid with painful musculoskeletal disorders such as low back pain and it negatively affects outcomes, including return to work. As psychologically-informed practice becomes more widely implemented without the immediate availability of behavioral health practitioners, safe and effective methods to screen for and appropriately triage depressive illness by nonbehavioral health practitioners are necessary. OBJECTIVES: To demonstrate the efficacy and validity of a method employed by non-behavioral health practitioners to screen for and appropriately triage musculoskeletal pain patients who also are experiencing depressive illness. METHODS: As part of a previously-published psychometric research study conducted in a community-based musculoskeletal pain rehabilitation program, a method was developed for nonbehavioral health practitioners to screen for and appropriately triage patients for co-morbid depressive illness, thus providing the current opportunity to examine the effects of depressive illness on work outcomes. The first step in the two-step process involves a 22-item questionnaire, providing scores used in the second step to triage for outside consultation with behavioral health practitioners. This paper describes the screening method and its application in an observational study of the impact of depressive illness on work outcomes. RESULTS: Among 156 consecutive patients who were presenting with musculoskeletal pain disorders to an outpatient rehabilitation program, 22.3% also were identified to have co-morbid clinical depression. The screening process allowed all patients to continue in the rehabilitation program. Those who were already receiving behavioral health care were encouraged to inform care providers of their participation in the program. Those who were not receiving behavioral health care were successfully triaged to care outside of the clinic. Depressive illness was found to affect success in the program, confirming the validity of the screening process for outpatient rehabilitation program participants experiencing chronic pain. CONCLUSIONS: A simple and effective depression screening process that triages patients without interruption of musculoskeletal treatment can be employed by nonbehavioral health practitioners. Because return to work outcomes were found to be negatively affected by depressive illness, this approach has the potential to improve overall program efficacy.

Correlates of a Single-Item Quality-of-Life Measure in People Aging with Disabilities.

OBJECTIVE: Practical quality-of-life (QOL) screening methods are needed to help focus clinical decision-making on what matters to individuals with disabilities. DESIGN: A secondary analysis of a database from a large study of adults aging with impairments focused on four diagnostic groups: cerebral palsy (n = 134), polio (n = 321), rheumatoid arthritis (n = 99), and stroke (n = 82). Approximately 20% of cases were repeated measures of the same individuals 3-5 yrs later. Functional levels, depression, and social interactions were assessed. The single-item, subjective, seven-point Kemp Quality of Life Scale measured QOL. For each diagnostic group, Kemp Quality of Life Scale responses were divided into low, average, and high QOL subgroups. Analysis of variance and Tukey honestly significant difference tests compared clinical characteristics among these subgroups. RESULTS: Duration of disability varied among the four groups. Within each group, QOL subgroups were similar in age, sex, and duration of disability. Low mean QOL was associated with lower functional level, higher depression scores, and lower social interaction (P < 0.001) in all four groups. In contrast, high mean QOL was associated with higher social interaction (P < 0.001). CONCLUSION: The Kemp Quality of Life Scale relates significantly to clinically relevant variables in adults with impairments. The scale's utility in direct clinical care merits further examination.

Predicting psychosocial outcomes using a brief measure of quality of life in a sample of people with spinal cord injury.

BACKGROUND: Spinal cord injury (SCI) significantly impacts an individual's quality of life (QOL). A brief and subjective measure of QOL is necessary to monitor the progress and outcomes of SCI rehabilitation. OBJECTIVE: To determine whether this measure of QOL was associated with clinically important physical and psychosocial outcomes in a sample of people with SCI, to determine how people with SCI scored on this measure of QOL, and to determine whether people with SCI scored differently than nondisabled individuals on the QOL scale. METHODS: Participants were 134 people with SCI (65% male; 35% female) and 227 nondisabled people (35% male; 65% female). Participants were assessed on a number of psychosocial and physiological variables at a large urban university and rehabilitation center. Variables examined were QOL, life satisfaction, depression, social interaction, pain, fatigue, and level of functioning. RESULTS: Participants with SCI reported more low QOL scores and fewer high QOL scores than the nondisabled group. For participants with SCI, QOL was positively related to life satisfaction and social interaction and negatively related to pain, fatigue, and depression. CONCLUSIONS: Participants with SCI scored lower on the QOL measure than those without a disability, although the difference was not clinically significant. QOL was unrelated to level of functioning; people may still experience a high QOL despite their physical limitations. Depression and social interaction were significantly related to QOL and should be secondary targets for intervention following SCI rehabilitation.

Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial.

OBJECTIVE/BACKGROUND: People with spinal cord injury (SCI) paraplegia can develop shoulder problems over time, which may also cause pain. Shoulder pain may complicate or interfere with a person's daily activities, social events, and their overall quality of life (QOL). The purpose of this study was to examine changes in social interaction and QOL after an exercise treatment for shoulder pain in people with SCI paraplegia. DESIGN: Fifty-eight participants with SCI paraplegia who were also experiencing shoulder pain were selected and randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12-week, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing. METHODS: Participants filled out self-report measures at baseline, 12 weeks later at the end of treatment, and at a 4-week follow-up. OUTCOME MEASURES: The Wheelchair User's Shoulder Pain Index (WUSPI), the Social Interaction Inventory (SII), and the Subjective Quality of Life Scale. RESULTS: From the baseline to the end of treatment, repeated-measures analysis of variance revealed a significant interaction between WUSPI and SII scores, P < 0.001, and between WUSPI and QOL scores, P < 0.001. CONCLUSION: Reductions in shoulder pain were related to significant increases in social participation and improvements in QOL. However, increases in social participation did not significantly affect improvements in QOL.

Strengthening and optimal movements for painful shoulders (STOMPS) in chronic spinal cord injury: a randomized controlled trial.

BACKGROUND: Shoulder pain is a common problem after spinal cord injury (SCI), with negative effects on daily activities and quality of life (QOL). OBJECTIVE: The purpose of this study was to determine the effect of an exercise program and instruction to optimize performance of upper-extremity tasks on shoulder pain in people with paraplegia from SCI. METHODS: Design Eighty individuals with paraplegia from SCI and shoulder pain were randomly assigned to receive either an exercise/movement optimization intervention or an attention control intervention. The exercise/movement optimization intervention consisted of a 12-week home-based program of shoulder strengthening and stretching exercises, along with recommendations on how to optimize the movement technique of transfers, raises, and wheelchair propulsion. The attention control group viewed a 1-hour educational video. Outcome measures of shoulder pain, muscle strength (force-generating capacity), activity, and QOL were assessed at baseline, immediately after intervention, and 4 weeks later. RESULTS: Shoulder pain, as measured with the Wheelchair User's Shoulder Pain Index, decreased to one third of baseline levels after the intervention in the exercise/movement optimization group, but remained unchanged in the attention control group. Shoulder torques, most 36-Item Short-Form Health Survey questionnaire (SF-36) subscale scores, and QOL scores also were improved in the exercise/movement optimization group, but not in the attention control group. Improvements were maintained at the 4-week follow-up assessment. Limitations Many of the outcome measures were self-reported, and the participant dropout rate was high in both groups. Additional studies are needed to determine whether the results of this study can be generalized to individuals with tetraplegia. CONCLUSIONS: This home-based intervention was effective in reducing long-standing shoulder pain in people with SCI. The reduction in pain was associated with improvements in muscle strength and health-related and overall QOL.

Goal striving and maladaptive coping in adults living with spinal cord injury: associations with affective well-being.

OBJECTIVE: The current study examined how goal engagement and two coping strategies (self-blame and denial) hypothesized to prevent successful disengagement relate to affective well-being among adults with a functional disability. METHOD: Ninety-nine community-dwelling adults (23 to 76 years old, 66 men) with spinal cord injury participated in structured interviews assessing affective well-being using the Positive and Negative Affect Scale (Watson, Clark, & Tellegen, 1988); goal engagement using a modified version of the Optimization, Primary, and Secondary Control Scale (Heckhausen, Schulz, & Wrosch, 1998); and self-blame and denial using items from Carver's (1997) Brief COPE Inventory. RESULTS: Greater goal engagement was significantly associated with positive but not negative affect. Greater use of self-blame and denial coping was associated with lower positive affect for older adults and higher negative affect across the age range.

Effects of assistive technology on functional decline in people aging with a disability.

This study used a randomized control group design to investigate the impact of an assistive technology and home modification intervention on function for individuals who are aging with a disability. There were 91 participants with polio, rheumatoid arthritis, cerebral palsy, spinal cord injury, stroke, and other impairments. Outcome data were collected at 12 and 24 months through in-home interviews using the Older Americans Resources and Services Instrument (OARS) and the Functional Independence Measure (FIM), and through monthly telephone contact on the hours of in-home care, hospitalizations, and acquisition of AT. The treatment group received an in-home evaluation of their equipment and home modification needs. All recommended AT and home modifications were provided and paid for in full or in part by the study. The control group received the standard community-available health care. A significant "group by time" interaction for the FIM suggested a slower decline in function for the treatment group over 2 years. Further analyses found that the treatment group was more likely to use equipment to maintain independence vs. personal assistance. This study supports the value of assistive technology for adults aging with a disability and suggests that it be provided earlier in the aging process.

Combating elder and dependent adult mistreatment: the role of the clinical psychologist.

Among the many different professionals who work to address elder and dependent adult mistreatment, the clinical psychologist performs a function that is not well documented. The experiences of a clinical psychologist attached to a medical response team and an elder abuse forensic center provide insight into this complex and multifaceted role. Case examples from an elder abuse forensic center illustrate the breadth of referral questions that a clinical psychologist addresses. This information may be of use to those who would argue that these services be made widely available to elder abuse professionals such as social workers, public guardians, and those in the criminal justice system. The case studies also may be useful for training purposes.

The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia.

BACKGROUND/OBJECTIVE: For persons with spinal cord injury (SCI), severe bodily pain is related to a lower quality of life. However, the effect of pain from a specific body region on quality of life has yet to be determined. The shoulder joint is a common site of pain among persons with SCI. Therefore, our purpose was to identify the relationship of self-reported shoulder pain with quality of life, physical activity, and community activities in persons with paraplegia resulting from SCI. METHODS: Eighty participants with shoulder pain who propel a manual wheelchair (mean age: 44.7 years; mean duration of injury: 20 years; injury level T1-L2) completed the following questionnaires: Wheelchair User's Shoulder Pain Index, Subjective Quality of Life Scale, Physical Activity Scale for Individuals with Physical Disabilities, and Community Activities Checklist. Correlations between shoulder pain scores and quality of life, physical activity, and community activities were determined using Spearman's rho test. RESULTS: Shoulder pain intensity was inversely related to subjective quality of life (r(s) =-0.35; P= 0.002) and physical activity (r(s) = -0.42; P < 0.001). Shoulder pain intensity was not related to involvement in community activities (r(s) = -0.07; P = 0.526). CONCLUSIONS: Persons with SCI who reported lower subjective quality of life and physical activity scores experienced significantly higher levels of shoulder pain. However, shoulder pain intensity did not relate to involvement in general community activities. Attention to and interventions for shoulder pain in persons with SCI may improve their overall quality of life and physical activity.

Elder financial abuse: an evaluation framework and supporting evidence.

OBJECTIVES: To develop a valid and reliable framework for evaluating cases of alleged elder financial abuse. DESIGN: Experienced experts in elder financial abuse rated a framework with eight elements. SETTING: Professionals attending an advanced training course on elder abuse. PARTICIPANTS: Deputy district attorneys (n=44), senior law enforcement detectives (n=59), Adult Protective Service workers, and public guardians and victim advocates (n=56) who had a combined total of 1,985 years of experience and who had investigated a total of 3,225 cases (mean of 13.1 years and 21.2 cases) were included. MEASUREMENTS: These experienced professionals were asked to rate how well an evaluative framework matched their experience with elder financial abuse using a 5-point rating scale ranging from very little to almost entirely. RESULTS: The mean rating for the model was 4.4 out of 5. About 90% of the sample rated it as almost entirely or very much matching their experience. There were no differences between professions. The reliability measure was 0.85. CONCLUSION: These results suggest a reliable and valid framework for evaluating cases of possible elder financial abuse.

Use of personal emergency response systems by older individuals with disabilities.

This article describes how older persons perceive and use personal emergency response systems (PERSs), including issues related to device design, and report reasons for nonuse of PERSs. Data for this study were collected through a semistructured questionnaire that included fixed and open-ended response questions. Six hundred six participants 60 years and older were surveyed. Descriptive statistics were used to report sample characteristics. The most often-stated reason for using a PERS was related to concerns with falling (40% of responses). Asked how a PERS has been helpful, 75.6% of participants expressed an enhanced feeling of security with their PERS. Lack of perceived need (57.0% of responses), cost (37.0%), and lack of knowledge of the device (23.7%) were the most frequently stated reasons for not using a PERS. This study found that, while PERSs provide benefits for many elders, there appear to be many older persons who could benefit who do not have one. Only 16% of participants in this study, all of whom had disabilities, used a PERS.

What the rehabilitation professional and the consumer need to know.

Many people with disabilities from early in life (eg, cerebral palsy,spinal cord injury, and polio) are beginning to live into middle and late life. Recent evidence indicates that these individuals often do not age in a typical manner. A large proportion of these people develop new medical, functional, and support problems by the time they reach their late 40s and early 50s. This article reviews many of those changes and points to some ways to help intervene. Changes in rehabilitation education and programs need to begin to incorporate these recent findings.

Advancing the field of elder mistreatment: a new model for integration of social and medical services.

PURPOSE: The purpose of this work is to describe the development and operation of a new model for integration of medical and social services. The Vulnerable Adult Specialist Team (VAST) provides Adult Protective Services (APS) and criminal justice agencies with access to medical experts who examine medical and psychological injuries of victims of elder abuse. DESIGN AND METHODS: This retrospective, descriptive analysis included community-dwelling elders and adults with disabilities who were reported for mistreatment and referred to VAST (n = 269). RESULTS: Most cases came from APS for mental status and physical examination for evidence of abuse. Cases referred to a medical response team (n = 269) were significantly different from cases that were not referred (n = 9,505). IMPLICATIONS: Ninety-seven percent of those who referred cases to VAST indicated that the team was helpful in confirming abuse, documenting impaired capacity, reviewing medications and medical conditions, facilitating the conservatorship process, persuading the client or family to take action, and supporting the need for law enforcement involvement. As a result, VAST has become institutionalized in our county. Amenable to replication, medical response teams for elder abuse may be useful in other counties across the nation.

Treatment of major depression in individuals with spinal cord injury.

OBJECTIVE: This study evaluated the effects of treating major depression in individuals with spinal cord injury (SCI), focusing on the degree of improvement and correlated changes that could be expected in 6 months of treatment. DESIGN: A pretreatment-posttreatment design was used. Random assignment to a nontreatment group could not be implemented ethically. Therefore, this study compared participants who declined treatment to persons who accepted treatment over a 24-month period. SETTING AND PARTICIPANTS: Participants were outpatients of a large urban rehabilitation center in southern California. Twenty-eight participants who accepted treatment were assigned to a treatment group; 15 individuals who declined treatment were assigned to a nontreatment group. The age of the participants ranged from 20 to 74 years. Varying levels of SCI dysfunction were represented. INTERVENTIONS: A 6-month combination of psychotherapy and antidepressant medication. OUTCOME MEASURES: A depression inventory, a community activities checklist, and a life satisfaction scale. RESULTS: A significant (P < 0.001) 57% reduction in depressive symptoms occurred in the treatment group, whereas there was no significant change in the nontreatment group. At the end of 6 months, 30% of participants had no depression, 42% had minor depression, and 29% still had major depression, but to a lesser degree. Community activities increased significantly over the treatment period, as did life satisfaction. CONCLUSION: The results suggest that depression is treatable in this population, although 6 months may not be sufficient to reach maximum benefit in all cases. This study further identified obstacles that limited the ability to randomize participants into treatment arms and made it difficult to deliver services to all those in need. Complications related to SCI, such as difficulties in transportation, likely restrict the ability to implement needed services to many individuals with SCI.

Guidelines for managing Alzheimer's disease: part I. Assessment.

Family physicians play a key role in assessing and managing patients with Alzheimer's disease and in linking the families of these patients to supportive services within the community. As part of comprehensive management, the family physician may be responsible for coordinating assessments of patient function, cognition, comorbid medical conditions, disorders of mood and emotion, and caregiver status. Suggestions for easily administered and scored assessment tools are provided, and practical tips are given for supporting primary caregivers, thereby increasing efficiency and quality of care for patients with Alzheimer's disease.

Guidelines for managing Alzheimer's disease: Part II. Treatment.

Once the clinical diagnosis of Alzheimer's disease has been made, a treatment plan must be developed. This plan should include cholinesterase inhibitor therapy to temporarily improve cognition or slow the rate of cognitive decline, management of comorbid conditions, treatment of behavioral symptoms and mood disorders, provision of support and resources for patient and caregiver, and compliance with state-mandated reporting requirements for driving impairment and elder abuse. The primary caregiver can be a valuable ally in communication, management of care, and implementation of the care plan. Patient symptoms and care needs change as Alzheimer's disease progresses. In the early stage of the disease, the family physician should discuss realistic expectations for drug therapy, solicit patient and family preferences on future care choices, and assist with advance planning for future care challenges. In the middle stage, the patient may exhibit behavioral symptoms that upset the caregiver and are difficult to manage. When the patient is in the advanced stage of Alzheimer's disease, the caregiver may need support to provide for activities of daily living, help in making a difficult placement decision, and guidance in considering terminal care options. Throughout the course of the disease, routine use of community resources allows care to be provided by a network of professionals, many of whom will be specialists in Alzheimer's disease.

Aging and spinal cord injury: medical, functional, and psychosocial changes.

Fifty years ago, people who had a spinal cord injury had very limited life expectancies. Today, these individuals can expect to live into their 60s, 70s, and beyond. Advances in rehabilitation, technology, surgery, and medicines have been chiefly responsible for this change. Recent research in both Europe and the United States now indicates that as these people age, they often develop medical and functional problems that are not as common in their nondisabled peers until much later in life. The importance of these "premature" age-related problems has led the National Institute on Disability and Rehabilitation Research to fund the Rehabilitation Research and Training Center (RRTC) on Aging With a Spinal Cord Injury at Rancho Los Amigos National Rehabilitation Center in Downey, California. This article summarizes some of the important findings from this RRTC and from other sources.