This narrative article on coping with tinnitus has four primary objectives. First, theoretical perspectives about defining and categorizing coping are discussed. Second, an overview of the empirical research on coping with tinnitus is provided, focusing on how coping with tinnitus has been measured and on the trends that were found in research on coping with tinnitus. Third, the problems related to the current state of research on coping with tinnitus are highlighted. Fourth, suggestions are provided on ways that researchers can improve research on coping with tinnitus.
Some individuals with mild cognitive impairment (MCI) experience not only cognitive deficits but also a decline in motor function, including postural balance. This pilot study sought to estimate the feasibility, user experience, and effects of a novel sensor-based balance training program. Patients with amnestic MCI (mean age 78.2 yr) were randomized to an intervention group (IG, n = 12) or control group (CG, n = 10). The IG underwent balance training (4 wk, twice a week) that included weight shifting and virtual obstacle crossing. Real-time visual/audio lower-limb motion feedback was provided from wearable sensors. The CG received no training. User experience was measured by a questionnaire. Postintervention effects on balance (center of mass sway during standing with eyes open [EO] and eyes closed), gait (speed, variability), cognition, and fear of falling were measured. Eleven participants (92%) completed the training and expressed fun, safety, and helpfulness of sensor feedback. Sway (EO, p = 0.04) and fear of falling (p = 0.02) were reduced in the IG compared to the CG. Changes in other measures were nonsignificant. Results suggest that the sensor-based training paradigm is well accepted in the target population and beneficial for improving postural control. Future studies should evaluate the added value of the sensor-based training compared to traditional training.
The Department of Veterans Affairs traumatic brain injury (TBI) screening program is intended to detect and expedite treatment for TBI and postconcussive symptoms. Between April 14, 2007, and May 31, 2012, of 66,089 Iraq and Afghanistan Veterans who screened positive on first-level TBI screening and later completed comprehensive TBI evaluation that includes the Neurobehavioral Symptoms Inventory, 72% reported moderate to very severe cognitive impairment (problems with attention, concentration, memory, etc.) that interfered with daily activities. This included 42% who were found not to have sustained combat-related mild TBI (mTBI). In contrast, 70.0% received a posttraumatic stress disorder (PTSD) diagnosis and 45.8% received a depression diagnosis. Compared with Veterans without mTBI, PTSD, or depression diagnoses, the lowest risk for self-reported cognitive impairment was in Veterans with confirmed mTBI only; a greater risk was found in those with PTSD diagnoses, with the greatest risk in Veterans with PTSD, depression, and confirmed mTBI, suggesting only a weakly additive effect of mTBI. These findings suggest that Veterans with multiple mental health comorbidities, not just those with TBI, report moderate to very severe cognitive impairment. Mental health treatment for conditions such as PTSD and depression (with or without TBI) may result in improvements in cognitive functioning and/or include assessment and support for Veterans experiencing cognitive problems.
We evaluated the ability of an individual with a high cervical spinal cord injury (SCI) to control a cursor on a computer screen using two different user interfaces: (1) head movements measured via a head-mounted orientation sensor and (2) electromyography (EMG) signals from four head and neck muscles acquired using a 4-channel implanted upper-limb neuroprosthesis that had been deployed in an earlier study. The subject moved the cursor to a set of targets on the screen in a two-dimensional, center-out, target-acquisition task, and his performance was evaluated with a variety of performance measures to assess both position and velocity control accuracy. The subject's performance with both command sources was also compared with the performance of a group of nondisabled subjects. Head orientation provided more accurate performance but was less responsive than EMG. Both command sources showed some directionally dependent performance, with movement to diagonally located targets being performed by a series of sequential motions rather than via straight paths. Overall, the SCI subject's performance with each command source was similar to that reported for a nondisabled population using the same interfaces and performing the same task.
Neuromuscular electrical stimulation (NMES) is a promising assistive technology for stroke rehabilitation. Here we present the design and development of a multimuscle stimulation system as an emerging therapy for people with paretic stroke. A network-based multichannel NMES system was integrated based on dual bus architecture of communication and an H-bridge current regulator with a power booster. The structure of the system was a body area network embedded with multiple stimulators and a communication protocol of controlled area network to transmit muscle stimulation parameter information to individual stimulators. A graphical user interface was designed to allow clinicians to specify temporal patterns and muscle stimulation parameters. We completed and tested a prototype of the hardware and communication software modules of the multichannel NMES system. The prototype system was first verified in nondisabled subjects for safety, and then tested in subjects with stroke for feasibility with assisting multijoint movements. Results showed that synergistic stimulation of multiple muscles in subjects with stroke improved performance of multijoint movements with more natural velocity profiles at elbow and shoulder and reduced acromion excursion due to compensatory trunk rotation. The network-based NMES system may provide an innovative solution that allows more physiological activation of multiple muscles in multijoint task training for patients with stroke.
Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.
Approximately 20% of current-era Veterans have sustained a traumatic brain injury (TBI), which can result in persistent postconcussive symptoms. These symptoms may disrupt family and social functioning. We explored psychiatric, postconcussive, and cognitive factors as correlates of objective functioning and subjective satisfaction in family and social relationships. At entry into a supported employment study, 50 unemployed Veterans with a history of mild to moderate TBI and current cognitive impairment were administered baseline assessments. Multivariate stepwise regressions determined that higher levels of depressive symptomatology were strongly associated with less frequent social contact, as well as lower subjective satisfaction with family and social relationships. Worse verbal fluency predicted less frequent social contact, whereas worse processing speed and switching predicted higher levels of subjective satisfaction with family relationships. The pattern of results remained similar when examining those Veterans with only mild TBI. Depressive symptoms and cognitive functioning may impact Veterans' social contact and satisfaction with family and social relationships. Evidence-based interventions addressing depression and cognition may therefore aid in improving community reintegration and satisfaction with social and family relationships.
Wrist orthoses (also known as splints, braces, or supports) are commonly used to support or restrict the motion of a weak or injured wrist. These orthoses generally function by stiffening the wrist joint. Therefore, choosing the proper orthosis (or improving orthoses) requires that we understand their stiffness properties. In this study, we present a method for measuring the stiffness of wrist orthoses, and we apply this method to 12 of the most common wrist orthoses. We found similarities and differences between these orthoses, indicating that different orthoses have different effects on the wrist joint and, presumably, on wrist behavior. In particular, all six orthoses with a stay on the volar side or the volar and dorsal sides added a significant amount of stiffness to the wrist joint. In contrast, only one of three orthoses with a stay on the dorsal side and none of the three orthoses without stays exhibited a significant amount of stiffness, calling into question their ability to support the wrist joint. This work lays a foundation for future studies investigating the effect of wrist orthosis stiffness on wrist behavior and how wrist orthosis stiffness can be designed to produce behavior that facilitates healing.
Because posttraumatic stress disorder (PTSD) is both prevalent and underrecognized, routine primary care-based screening for PTSD has been implemented across the Veterans Health Administration. PTSD is frequently complicated by the presence of comorbid chronic pain, and patients with both conditions have increased symptom severity and poorer prognosis. Our objective was to determine whether the presence of pain affects diagnosis and treatment of PTSD among Department of Veterans Affairs (VA) patients who have a positive PTSD screening test. This retrospective cohort study used clinical and administrative data from six Midwestern VA medical centers. We identified 4,244 VA primary care patients with a positive PTSD screen and compared outcomes for those with and without a coexisting pain diagnosis. Outcomes were three clinically appropriate responses to positive PTSD screening: (1) mental health visit, (2) PTSD diagnosis, and (3) new selective serotonin reuptake inhibitor (SSRI) prescription. We found that patients with coexisting pain had a lower rate of mental health visits than those without pain (hazard ratio: 0.889, 95% confidence interval: 0.821-0.962). There were no significant differences in the rate of PTSD diagnosis or new SSRI prescription between patients with and without coexisting pain.
Documentation of clinical outcomes is increasingly expected in delivery of prosthetic services and devices. However, many outcome measures suitable for use in clinical care and research have not been psychometrically tested with prosthesis users. The aim of this study was to determine test-retest reliability, mode-of-administration (MoA) equivalence, standard error of measurement (SEM), and minimal detectable change (MDC) of standardized, self-report instruments that assess constructs of importance to people with lower limb loss. Prosthesis users (n = 201) were randomly assigned to groups based on MoA (i.e., paper, electronic, or mixed-mode). Participants completed two surveys 2 to 3 d apart. Instruments included the Prosthetic Limb Users Survey of Mobility, Prosthesis Evaluation Questionnaire-Mobility Subscale, Activities-Specific Balance Confidence Scale, Quality of Life in Neurological Conditions-Applied Cognition/General Concerns, Patient-Reported Outcomes Measurement Information System Profile, and Socket Comfort Score. Intraclass correlation coefficients indicated all instruments are appropriate for group-level comparisons and select instruments are suitable for individual-level applications. Several instruments showed evidence of possible floor and ceiling effects. All were equivalent across MoAs. SEM and MDC were quantified to facilitate interpretation of outcomes and change scores. These results can enhance clinicians' and researchers' ability to select, apply, and interpret scores from instruments administered to prosthesis users.
We characterized physical activity (PA) and its relation to physical function and number of comorbidities in people with diabetes and transtibial amputation (AMP), people with diabetes without AMP, and nondisabled adults without diabetes or AMP. Twenty-two individuals with type 2 diabetes mellitus (DM) and transtibial amputation (DM+AMP), 11 people with DM, and 13 nondisabled participants were recruited for this cross-sectional cohort study. Measures included PA volume and intensity, a Timed Up and Go test, a 2-min walk test, and number of comorbidities. The nondisabled group performed greater amounts of PA than the DM group, who performed greater amounts of PA than the DM+AMP group. PA was related to physical function in the DM group and in the DM+AMP group, whereas no such relationship existed in the nondisabled group. PA was not related to number of comorbidities in any group. These findings suggest the ability to walk may affect overall performance of PA. Alternately, PA may alleviate walking problems. This possibility is of interest because issues with walking may be modifiable by improved levels and intensity of PA. PA's lack of relation to number of comorbidities suggests that factors beyond multiple morbidities account for group differences in PA.
The purpose of this study was to quantify the deficit rates for transfer component skills in a Veteran cohort and explore the relationship between deficit rates and subject characteristics. Seventy-four men and 18 women performed up to four transfers independently from their wheelchair to a mat table while a therapist evaluated their transfer techniques using the Transfer Assessment Instrument. The highest deficit rates concerned the improper use of handgrips (63%). Other common problems included not setting the wheelchair up at the proper angle (50%) and not removing the armrest (58%). Veterans over 60 yr old and Veterans with moderate shoulder pain were more likely to set up their wheelchairs inappropriately than younger Veterans (p = 0.003) and Veterans with mild shoulder pain (p = 0.004). Women were less likely to remove their armrests than men (p = 0.03). Subjects with disabilities other than spinal cord injury were less inclined to set themselves up for a safe and easy transfer than the subjects with spinal cord injury (p ≤ 0.001). The results provide insight into the disparities present in transfer skills among Veterans and will inform the development of future transfer training programs both within and outside of the Department of Veterans Affairs.
Veterans with posttraumatic stress disorder (PTSD) and their families require resources to cope with postdeployment readjustment. Responding to this need, the current study examined a brief Internet-based intervention that provided Veterans' families with psychoeducation on postdeployment readjustment. Participants were 103 dyads of Veterans with probable PTSD and a designated family member/partner. Dyads were randomized to an intervention group, in which the family member completed the intervention, or to a control group with no intervention. Each member of the dyad completed surveys at baseline and 2 mo follow-up. Family member surveys focused on perceived empowerment, efficacy to provide support, and communication (perceived criticism and reactivity to criticism). Veteran surveys assessed perceived family support and communication. Results showed that Veterans in the intervention group reported decreases in reactivity to criticism but also decreased perceived family support. No significant differences were observed in outcomes reported by family members. This preliminary study provides an early understanding of this novel outreach program, as well as the challenges inherent with a very brief intervention. Future research can build on the current study by more closely evaluating the communication changes that occur with this form of intervention and whether greater intervention intensity is needed.CLINICAL TRIAL REGISTRATIONClinical Trials Identifier: NCT01554839.
Anxiety disorders are common and debilitating in older individuals, yet anxiety is often not formally assessed in primary care. We conducted a quality improvement project to examine the feasibility of implementing a brief anxiety assessment, the Geriatric Anxiety Inventory (GAI), in a Department of Veterans Affairs geriatric primary care clinic. We compared the GAI with a depression assessment, the 15-item Geriatric Depression Scale (GDS-15). Fifty older Veterans (mean = 78.5 +/- 7.4 yr) completed the GAI and GDS-15. Mean completion time and feedback to patients was brief (6.20 min; n = 10). Good internal consistency (alpha = 0.82) was found for GAI scores. Patients with psychiatric diagnoses obtained significantly higher GAI scores (mean = 4.73 +/- 1.15) compared with patients without psychiatric diagnoses (mean = 1.15 +/- 1.86, t(11.46) = -3.10, p = 0.01). Findings suggest that the GAI is acceptable to patients but may not be suitable for differentiating anxiety symptoms or disorders from depression. Interdisciplinary team members continued to implement the GAI after project completion to screen for and track anxiety symptoms in our geriatric primary care patients. Detecting anxiety with the GAI had the benefit of allowing providers to initiate conversations about available treatments and track symptoms as part of noting treatment progress.
Mobility scooters are three- or four-wheeled power mobility devices regularly used by people who have difficulty ambulating. They also differ from power wheelchairs in terms of their driving controls, programmability, seating, and mounting method. Given their growing popularity and anecdotal concerns around their use, a scoping review was undertaken to identify empirical research about mobility scooters and to analyze their study design and purpose. Data sources included MedLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and PsychINFO. Thirty-two studies met the inclusion criteria. Most studies were descriptive in nature and reported information about scooter users' demographics, scooter-related activities, and accidents. The most common study design was a pre- and postintervention followed by a cross-sectional survey and retrospective review. Despite the increasing use of mobility scooters, surprisingly little scooter-related research has been conducted. Given the nature of most of the research in this area, further empirical evidence is needed to develop a better understanding about the frequency and causes of scooter accidents and the efficacy of interventions to improve users' skills, mobility, and safety.
The goals of this study were to describe clinical practice patterns associated with the Veterans Health Administration's (VHA's) Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and determine whether practice patterns vary by patient, provider, or facility characteristics. Veterans (N = 614) who had initial healthcare visits between 2008 and 2011 and who had previously completed the VHA's traumatic brain injury (TBI) screen and subsequent CTBIE were drawn from a national database. Participants were primarily male (95%) with a mean age of 29.8 yr (standard deviation = 8). Chart reviews were conducted on a random sample of charts with completed CTBIEs from 21 sites. Using a cross-sectional design, patient- and facility-specific variables were investigated as potential predictors of practice variation. During the study period, 79% of patients in this national sample were screened within 1 d of their initial healthcare visit and 65% were evaluated via CTBIE within 30 d of screening. Provider and participant characteristics were generally not associated with timeliness. The CTBIE was completed by individuals versus teams at comparable rates. Much of what occurred during the evaluation, beyond TBI-specific procedures, were medical assessments, such as review of medications and other substances.
Improving the functionality of prosthetic hands with noninvasive techniques is still a challenge. Surface electromyography (sEMG) currently gives limited control capabilities; however, the application of machine learning to the analysis of sEMG signals is promising and has recently been applied in practice, but many questions still remain. In this study, we recorded the sEMG activity of the forearm of 11 male subjects with transradial amputation who were mentally performing 40 hand and wrist movements. The classification performance and the number of independent movements (defined as the subset of movements that could be distinguished with >90% accuracy) were studied in relationship to clinical parameters related to the amputation. The analysis showed that classification accuracy and the number of independent movements increased significantly with phantom limb sensation intensity, remaining forearm percentage, and temporal distance to the amputation. The classification results suggest the possibility of naturally controlling up to 11 movements of a robotic prosthetic hand with almost no training. Knowledge of the relationship between classification accuracy and clinical parameters adds new information regarding the nature of phantom limb pain as well as other clinical parameters, and it can lay the foundations for future "functional amputation" procedures in surgery.
Dynamic arm supports are provided to assist with activities of daily living (ADLs) in people with limited upper-limb function. However, the perceived functional benefit of these devices in daily life is unknown. Insight into the functional benefit may give direction to the development of new devices and may affect the factors that patients and their health care providers consider during the selection process of a device. A cross-sectional study involving 23 Dutch experienced dynamic arm support users was performed in the Netherlands. The study included a questionnaire, an interview, and an observation of ADL task performance in the domestic setting. Twenty participants completed this study. Five users had a large perceived functional benefit, nine a moderate benefit, and five no benefit (one was unable to indicate the benefit). People with limited functional abilities benefited most. Participants varied in the amount of device use, activities the device is used for, and reasons for using (or not using) the device. On an individual level, selection using a selection tool and a good evaluation of the prescription could improve user-device matches.
Successful organizational improvement processes depend on application of reliable metrics to establish targets and to monitor progress. This study examined the utility of the Pain Care Quality (PCQ) extraction tool in evaluating implementation of the Stepped Care Model for Pain Management at one Veterans Health Administration (VHA) healthcare system over 4 yr and in a non-VHA Federally qualified health center (FQHC) over 2 yr. Two hundred progress notes per year from VHA and 150 notes per year from FQHC primary care prescribers of long-term opioid therapy (>90 consecutive days) were randomly sampled. Each note was coded for the presence or absence of key dimensions of PCQ (i.e., pain assessment, treatment plans, pain reassessment/outcomes, patient education). General estimating equations controlling for provider and facility were used to examine changes in PCQ items over time. Improvements in the VHA were noted in pain reassessment and patient education, with trends in positive directions for all dimensions. Results suggest that the PCQ extraction tool is feasible and may be responsive to efforts to promote organizational improvements in pain care. Future research is indicated to improve the reliability of the PCQ extraction tool and enhance its usability.
Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests the pain management for these Veterans may need to be tailored to take CMI into consideration.
