Music-instruction intervention for treatment of post-traumatic stress disorder: a randomized pilot study.

BACKGROUND: Post-traumatic Stress Disorder (PTSD) is a common sequelae of severe combat-related emotional trauma that is often associated with significantly reduced quality of life in afflicted veterans. To date, no published study has examined the effect of an active, music-instruction intervention as a complementary strategy to improve the psychological well-being of veterans with PTSD. The purpose of this study was to examine the feasibility and potential effectiveness of an active, music-instruction intervention in improving psychological health and social functioning among Veterans suffering from moderate to severe PTSD. METHODS: The study was designed as a prospective, delayed-entry randomized pilot trial. Regression-adjusted difference in means were used to examine the intervention's effectiveness with respect to PTSD symptomatology (primary outcome) as well as depression, perceptions of cognitive failures, social functioning and isolation, and health-related quality of life (secondary outcomes). RESULTS: Of the 68 Veterans who were self- or provider-referred to the program, 25 (36.7%) were ineligible due to (i) absence of a PTSD diagnosis (n = 3); participation in ongoing intense psychotherapy (n = 4) or inpatient substance abuse program (n = 2); current resident of the Domiciliary (n = 8) and inability to participate due to distance of residence from the VA (n = 8). Only 3 (4.4%) Veterans declined participation due to lack of interest. The mean age of enrolled subjects was 51 years old [range: 22 to 76]. The majority was male (90%). One-quarter were African American or Black. While 30% report working full or part time, 45% were retired due to disability. Slightly over one-quarter were veterans of the OEF/OIF wars. Estimates from regression-adjusted treatment effects indicate that the average PTSD severity score was reduced by 9.7 points (p = 0.01), or 14.3% from pre- to post-intervention. Similarly, adjusted depressive symptoms were reduced by 20.4% (- 6.3 points, p = 0.02). There were no statistically significant regression-adjusted effects on other outcomes, although the direction of change was consistent with improvements. CONCLUSIONS: Our findings suggest that the active, music-instruction program holds promise as a complementary means of ameliorating PTSD and depressive symptoms among this population. TRIAL REGISTRATION: Trial registered at ClinicalTrials.gov with protocol number Medical College of Wisconsin PRO00019269 on 11/29/2018 (Retrospectively registered).

Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study.

OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.

Identification of cervical radiculopathies: optimizing the electromyographic screen.

OBJECTIVE: To determine the optimal electromyography screening examination of the upper limb that ensures detection of those cervical radiculopathies, which can be electrodiagnostically confirmed, yet minimizes the number of muscles studied. DESIGN: A prospective multicenter study was conducted from May 1996 to September 1997 at five institutions. Patients who were referred to participating electrodiagnostic laboratories with suspected cervical radiculopathy were recruited. A standard set of muscles were examined by needle electromyography. Patients with electrodiagnostically confirmed cervical radiculopathies, based on electromyography findings, were selected for analysis. Muscle screens were tested against this group to determine whether the screen identified the patients with radiculopathy. RESULTS: There were 101 patients with cervical radiculopathies representing all cervical root levels. When paraspinal muscles were one of the screening muscles, five muscle screens identified 90% to 98% of radiculopathies, six muscle screens identified 94% to 99%, and seven muscle screens identified 96% to 100%. When paraspinal muscles were not part of the screen, eight distal limb muscles recognized 92% to 95% of radiculopathies. CONCLUSION: This study demonstrated that six muscle screens including paraspinal muscles yielded consistently high identification rates. Studying additional muscles led to marginal increases in identification.

Identifying lumbosacral radiculopathies: an optimal electromyographic screen.

OBJECTIVE: The objective of this study was to determine prospectively the optimal electromyographic screening examination of the lower limb that ensures identification of those lumbosacral radiculopathies that can be electrodiagnostically confirmed, yet minimizes the number of muscles studied. DESIGN: A prospective multicenter study was conducted from May 1996 to September 1997. Patients with suspected lumbosacral radiculopathy referred to participating electrodiagnostic laboratories were recruited and examined by needle electromyography using a standard set of muscles. Patients with electrodiagnostically confirmed lumbosacral radiculopathies were selected for analysis. Various muscle screens were tested against this group of patients with radiculopathies to determine the frequency with which each screen identified the patient with radiculopathy. RESULTS: There were 102 patients identified. When paraspinal muscles were one of the screening muscles, four-muscle screens identified 88-97% of the radiculopathies, five-muscle screens identified 94-98%, and six-muscle screens 98-100%. When paraspinal muscles were not part of the screen, identification rates were lower for all screens, and eight distal muscles were necessary to identify about 90% of the radiculopathies. CONCLUSIONS: Six-muscle screens with paraspinal muscles yielded consistently high identification rates. Studying additional muscles produced no improvements in identification.

Potential and active family caregivers: changing networks and the "sandwich generation".

Informal family care giving has been a traditional mainstay of care for the frail elderly. As the Baby Boomers approach retirement and old age, it is not clear that society can continue to rely on informal arrangements. The 1984 and 1994 National Long Term Care Surveys were used as sources for examining changes over a decade in the population of chronically disabled elderly, their sources of care, and the characteristics of family caregivers. The results showed that although the total number of active family caregivers declined, a constant number of primary caregivers was looking after recipients who were more severely disabled. Members of the "sandwich generation" and full-time workers maintained or even increased their participation as primary caregivers. The competing demands confronting these caregivers and the higher disability levels among care recipients probably contributed to the growing pattern of reliance on formal care, a situation that is likely to continue.

Predicting electrodiagnostic outcome in patients with upper limb symptoms: are the history and physical examination helpful?

OBJECTIVE: To determine the effectiveness of medical history and physical examination in predicting electrodiagnostic outcome in patients with suspected cervical radiculopathy. METHODS: Data on 183 subjects prospectively collected at five different electrodiagnostic laboratories were analyzed (96 cervical radiculopathies, 45 normal studies, and 42 abnormal electrodiagnostic findings other than radiculopathy). The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratios were determined for symptoms and neurologic signs. RESULTS: Symptoms of numbness, weakness, and tingling were associated with twice the probability of having abnormal electrodiagnostic study results in general, yet were not helpful in identifying a cervical radiculopathy. All single and combined physical examination components had poor sensitivities, with the exception of weakness, but much higher specificities. Patients with either weakness or reduced reflexes on physical examination were up to five times more likely to have abnormal electrodiagnostic findings. In subjects with any abnormal neurologic sign, the sensitivity improved to 84%, the positive predictive value was 79%, but the specificity was low (44%). Of those subjects with normal physical examination results, almost one half had an abnormal electrodiagnostic study result (negative predictive value 52%). CONCLUSIONS: In a population of patients with suspected cervical radiculopathy, medical history and physical examination are helpful yet not sufficient to predict the electrodiagnostic outcome.

Symptom duration and spontaneous activity in lumbosacral radiculopathy.

OBJECTIVES: A long-held notion in the electrodiagnostic literature is that paraspinal muscles tend to show spontaneous activity (fibrillations and positive sharp waves) on needle electromyography, early on in a lumbosacral radiculopathy, and that more distal muscles become abnormal later in the disease process. The purpose of this study was to determine whether paraspinal muscle and other major proximal and distal muscle spontaneous activity is related to a lumbosacral radiculopathy symptom duration. METHODS: A multicenter, prospective study that collected standard information on history, physical examination, and electrodiagnostic findings in patients with electrodiagnostically confirmed lumbosacral radiculopathies was undertaken. RESULTS: Multivariate probit analyses of 96 patients identified with a lumbosacral radiculopathy showed no evidence of correlation between spontaneous activity in the paraspinal muscles and symptom duration. Symptom duration was also nonsignificant in nine of the remaining ten lower limb muscles analyzed. CONCLUSION: These findings emphasize the limitations of using symptom duration when interpreting electrodiagnostic findings in lumbosacral radiculopathy.

Effect of history and exam in predicting electrodiagnostic outcome among patients with suspected lumbosacral radiculopathy.

OBJECTIVE: To determine the extent to which the history and physical examination predict the outcome of the electrodiagnostic (EDX) evaluation in patients with suspected lumbosacral radiculopathy. DESIGN: Data for 170 subjects referred for low-back and lower limb symptoms were prospectively collected at five EDX laboratories. The sensitivity, specificity, positive and negative predictive values, and odds ratios were determined for symptoms and neurologic signs. RESULTS: Symptoms were not significantly associated with an EDX study or a lumbosacral radiculopathy. The physical examination was better at predicting that an EDX study would be abnormal in general than it was at predicting a lumbosacral radiculopathy in particular. Of those subjects with normal physical examinations, 15%-18% still had abnormal EDX findings. CONCLUSIONS: In a population of patients referred for an EDX study, the history and physical examination alone cannot reliably predict electrodiagnostic outcome.

Rehabilitation and the long-term outcomes of persons with trauma-related amputations.

OBJECTIVE: To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes. DESIGN: Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation. PARTICIPANTS: Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded. RESULTS: Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes. CONCLUSIONS: These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.

The relation between stress fractures and bone mineral density: evidence from active-duty Army women.

OBJECTIVE: To determine if bone mineral density (BMD) is associated with the probability of stress fractures in premenopausal women. DESIGN: Case-control study. SETTING: Large Army post, Fort Lewis, WA. PARTICIPANTS: Twenty-seven active duty Army women with documented stress fractures within the last 2 years and 158 female controls. METHODS AND MAIN RESULTS: All subjects were examined and interviewed. BMD of the femoral neck and posteroanterior lumbar spine (L2-L4) was measured using dual energy X-ray absorptiometry. Univariate comparisons revealed no significant differences in BMD of the femoral neck or lumbar spine between groups. Women with stress fractures had a significantly higher exercise intensity (428 vs 292 minutes per week, p<.05) and were more likely to be entry-level enlisted soldiers (63% vs. 44%, p<.05) than those without stress fractures. Multivariate analyses revealed a strong negative association between femoral neck BMD and the probability of stress fractures (lower BMD, higher risk). Exercise intensity and body mass index had a significant positive effect on BMD of the femoral neck and lumbar spine, yet both were associated with an increased probability of stress fractures. CONCLUSIONS: Femoral neck BMD was significantly associated with the probability of stress fractures. Optimal training programs should balance the beneficial indirect effect of increased exercise (through increased BMD) with its detrimental direct effect on stress fractures.

Parental marital disruption and intergenerational transfers: an analysis of lone elderly parents and their children.

Although one of the most marked demographic trends observed over the twentieth century is the increased rate of divorce, relatively little research has explored the effects of these changing marital patterns in the context of an aging society. Using a sample of lone elderly parents and their adult children, we analyze the direct and indirect effects of marital disruption on four important dimensions of intergenerational transfers: coresidence, financial assistance, adult children's provision of informal care, and parental purchase of paid care. Our findings suggest that divorce has deleterious effects on intergenerational transfers, particularly for elderly fathers. Remarriage further reduces exchange. Our results reveal that parents engage in lower levels of transfers with stepchildren relative to biological children. Moreover, intergenerational transfers are sensitive to characteristics of biological children but not to those of stepchildren. Taken together, these results suggest that exchange at the end of the life course continues to be adversely affected by marital disruption.

Cervical radiculopathies: relationship between symptom duration and spontaneous EMG activity.

The purpose of this multicenter study was to prospectively examine whether denervation in paraspinal muscles (PSM) and in other major proximal and distal muscles is related to symptom duration in cervical radiculopathies (CRs). Information was collected on 93 electrodiagnostically confirmed CRs using standardized history, physical examination, and electromyographic (EMG) screens. Multivariate, maximum-likelihood estimates showed no evidence of correlation between PSM spontaneous activity and symptom duration. Symptom duration was also nonsignificant in eight of the remaining nine upper limb muscles analyzed. We conclude that the probability of spontaneous activity is not related to symptom duration. Clinicians, therefore, should refrain from interpreting electrodiagnostic findings based upon duration of symptoms.

Cervical paraspinal muscle abnormalities and symptom duration: a multivariate analysis.

The purpose of this study was to determine whether paraspinal and other major proximal and distal muscle spontaneous activity (SA) is related to cervical radiculopathy (CR) symptom duration. A multivariate analysis of 124 (retrospectively identified) electrodiagnostically confirmed CRs was used to test these hypotheses. The results showed no evidence of correlation between SA and symptom duration for any of the upper limb muscles analyzed.

Relationship between muscle abnormalities and symptom duration in lumbosacral radiculopathies.

A long held notion in the electrodiagnostic literature is that paraspinal muscles tend to show electromyographic abnormalities early on in a lumbosacral radiculopathy and that more distal muscles become abnormal later in the disease process. The purpose of this study was to determine whether paraspinal muscles and other major proximal and distal muscle abnormalities are related to lumbosacral radiculopathy symptom duration. A multivariate logit analysis of 139 patients (retrospectively identified) with electrodiagnostically confirmed lumbosacral radiculopathies was used to test these hypotheses. Maximum likelihood estimates showed no evidence of correlation between abnormal paraspinal muscles and symptom duration. Symptom duration was also insignificant for the remaining five lower limb muscles analyzed. We conclude that the probability of having electromyographic abnormalities is not related to symptom duration. A prospective study is needed to confirm these findings. Nonetheless, clinicians should use caution when interpreting electrodiagnostic findings based on symptom duration.

Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study.

OBJECTIVE: To examine patterns of trauma-related amputations over time by age and gender of the patient and by level and type of amputation, and to explore factors affecting acute care length of stay and discharge to inpatient rehabilitation. DESIGN: Population-based hospital discharge data for Maryland from 1979 through 1993. PARTICIPANTS: Patients (N = 6,069) discharged with either (1) a principal or secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2) a procedure code for a lower or upper limb amputation in combination with a principal diagnosis of an extremity injury or injury-related complication. RESULTS: Incidence of major amputations declined 3.4% (p < .05) annually from 1.88 per 100,000 in 1979 to 1.07 per 100,000 in 1993. Incidence of minor amputations declined 4.8% (p < .05) annually from 10.8 per 100,000 in 1979 to 4.7 per 100,000 in 1993. Acute care length of stay for trauma-related amputations declined 40% over the study period and was significantly affected by the patient's payer source, amputation level, and injury characteristics. Of the patients with a major amputation, 15% were discharged to inpatient rehabilitation; 60% were discharged directly home. More proximal amputation levels, presence of severe injuries to other body systems, and acute care at a designated trauma center significantly increased the likelihood of disposition to inpatient rehabilitation. The leading causes of trauma-related amputation were injuries involving machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%). CONCLUSIONS: Findings suggest a substantial decline in incidence rates of both major and minor amputations over the 15-year study period, a low rate of disposition to inpatient rehabilitation services of patients sustaining major amputations, and an apparent role of firearms as a cause of trauma-related amputations in patients younger than 25 years of age. The consequences of increasingly shorter acute care hospital stays and low rates of discharge to inpatient rehabilitation on the long-term outcomes of persons who have had traumatic amputation should be examined.