Comorbidity of Pain and Depression Among Persons With Traumatic Brain Injury

Objective

To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI).

Design

Longitudinal survey design with 1-year follow-up.

Setting

Inpatient rehabilitation and the community.

Participants

Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥4 were classified as having pain, and participants with PHQ-9 scores ≥10 were classified as depressed.

Results

Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001).

Conclusions

Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time.     

Depression among white and nonwhite caregivers of the chronically critically ill

Purpose

The study aimed to describe characteristics of caregivers of chronically critically ill (CCI) patients, describe key outcomes (depression, employment, physical health), and examine race as one of several predictors of post-hospital depressive symptoms.

Materials and Methods

This was a prospective study of caregivers of hospital survivors of prolonged (>72 hours) mechanical ventilation. Caregivers were interviewed at admission to the intensive care unit (ICU) and 2 months post-discharge.

Results

Patients discharged to an institution had a high risk of post-hospital mortality (odds ratio, 8.61; P = .01). Caregivers of patients residing in an institution 2 months post-discharge had greater odds of being depressed than caregivers of patients residing at home (odds ratio, 2.75; P = .001). Nonwhite caregivers of patients residing in an institution had the least improvement in depression over time. Predictors of depression 2 months post-discharge were depression during hospitalization (P = .001), sex (P = .019), health status (P = .009), and residence of the patient (P = .001), with no change based on race. Almost 50% of employed caregivers had a reduction in paid work. There was a significant reduction in physical health status over time (P = .001) with no difference based on race.

Conclusions

Caregivers of CCI patients are at risk for depression post-hospital discharge. Nonwhite caregivers of patients residing in an institution 2 months post-discharge are at highest risk for depression.     

Psychological Distress,Quality of Life,and Burden in Caregivers During Community Reintegration After Spinal Cord Injury

Objectives

To examine relations between psychological distress, health-related quality of life (HR-QOL), and burden among caregivers of people with traumatic spinal cord injury (SCI) over time, and to determine whether the data are more consistent with a wear and tear or adaptation trajectory.

Design

Prospective longitudinal cohort study with measurements at 4 time points (6wk prior to discharge from subacute inpatient rehabilitation and 6wk, 1y, and 2y postdischarge to community).

Setting

Rehabilitation units.

Participants

Participants (N=44; spouses, parents, others) nominated as a primary caregiver by the person with SCI.

Interventions

Not applicable.

Main Outcome Measures

General Health Questionnaire-28 (GHQ-28), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and Caregiver Strain Index (CSI) assessed the extent of psychological distress, HR-QOL, and burden, respectively, among caregivers. Functional status and community participation/care needs of the persons with SCI were assessed by the FIM and Craig Handicap Assessment and Reporting Technique, respectively.

Results

Multilevel piecewise models showed that psychological distress (GHQ-28 score) decreased significantly after discharge (slope estimate =−.03, P<.008). At the predischarge time point, the caregivers’ mental component summary score on the SF-36 was significantly lower than Australian national norms. The scores improved from predischarge to 6 weeks postdischarge (slope estimate =.39, P<.001), but they did not change significantly across the following 2 time points (slope estimate =.02, P=.250). At all 3 postdischarge time points, the mental component summary scores were not significantly different to national norms. In contrast, the physical component summary score of the SF-36 did not significantly change across the predischarge and 6-week postdischarge time points (slope estimate =−.14, P=.121) and the 3 postdischarge time points (slope estimate <.01, P=.947). Scores at all 4 time points were not significantly different to the national norms. Caregiver burden showed no significant change over the study period (predischarge to 6wk postdischarge slope estimate =.02, P=.426; 3 postdischarge time point slope estimates <−.01, P=.334). Reflecting this, 42% of caregivers met CSI caseness criterion at the first time point, and 46% met the criterion at the fourth (2y) time point. Higher burden was significantly correlated with increased hours of care being provided by the caregiver and lower FIM scores and lower community participation (for the person with SCI) at each time point. Psychological distress correlated with caregiver burden at 6 weeks and 1 year postdischarge but not at 2 years postdischarge.

Conclusions

The trajectory of scores for psychological distress and HR-QOL was consistent with caregiver adaptation to the challenge of providing support to a person with SCI in the early postdischarge period. Caregiver burden did not display similar reductions but did not worsen over the study period.     

The Impact of Stigma on Community Reintegration of Veterans With Traumatic Brain Injury and the Well-Being of Their Caregivers

Objective

To assess the association between perceived stigma and discrimination and caregiver strain, caregiver well-being, and patient community reintegration.

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: An exploratory comparative design

Background

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

Objectives

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

Design

Cross-sectional analytic study.

Settings

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

Participants

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

Methods

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

Results

The results show greater burden among adult-child caregivers (p < .05), who experience more feelings of guilt (p < .001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p < .001). Living with the patient has a notable influence on burden among adult children (p < .001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p < .05) and progressively worse mental health (p < .01). However, the correlations between burden and mental health were strongest in daughters (p < .001).

Conclusion

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.     

Gabapentinoids Are Effective in Decreasing Neuropathic Pain and Other Secondary Outcomes After Spinal Cord Injury: A Meta-Analysis

Objective

To examine the effectiveness of gabapentin and pregabalin in diminishing neuropathic pain and other secondary conditions in individuals with spinal cord injury (SCI).

Data Sources

A systematic search was conducted using multiple databases for relevant articles published from 1980 to June 2013.

Study Selection

Controlled and uncontrolled trials involving gabapentin and pregabalin for treatment of neuropathic pain, with ≥3 subjects and ≥50% of study population with SCI, were included.

Data Extraction

Two independent reviewers selected studies based on inclusion criteria and then extracted data. Pooled analysis using Cohen's d to calculate standardized mean difference (SMD), SE, and 95% confidence interval (CI) for primary (pain) and secondary outcomes (anxiety, depression, sleep interference) was conducted.

Data Synthesis

Eight studies met inclusion criteria. There was a significant reduction in the intensity of neuropathic pain at <3 months (SMD=.96±.11; 95% CI, .74–1.19; P<.001) and between 3 and 6 months (SMD=2.80±.18; 95% CI, 2.44–3.16; P<.001). A subanalysis found a significant decrease in pain with gabapentin (SMD=1.20±.16; 95% CI, .88–1.52; P<.001) and with pregabalin (SMD=1.71±.13; 95% CI, 1.458–1.965; P<.001). A significant reduction in other SCI secondary conditions, including sleep interference (SMD=1.46±.12; 95% CI, 1.22–1.71; P<.001), anxiety (SMD=1.05±.12; 95% CI, .81–1.29; P<.001), and depression (SMD=1.22±.13; 95% CI, .967–1.481; P<.001) symptoms, was shown. A significantly higher risk of dizziness (risk ratio [RR]=2.02, P=.02), edema (RR=6.140, P=.04), and somnolence (RR=1.75, P=.01) was observed.

Conclusions

Gabapentin and pregabalin appear useful for treating pain and other secondary conditions after SCI. Effectiveness comparative to other analgesics has not been studied. Patients need to be monitored closely for side effects.     

Relationship Between Ultrasonographic,Electromyographic, and Clinical Parameters in Adult Stroke Patients With Spastic Equinus: An Observational Study

Objective

To find more accurate indices that could affect decisions in spasticity treatment by investigating the relation between ultrasonographic, electromyographic, and clinical parameters of the gastrocnemius muscle in adults with spastic equinus after stroke.

Design

Observational study.

Setting

University hospitals.

Participants

Chronic patients with stroke with spastic equinus (N=43).

Interventions

Not applicable.

Main Outcome Measures

Ultrasonographic features were spastic gastrocnemius muscle echo intensity, muscle thickness, and posterior pennation angle of the gastrocnemius medialis (GM) and gastrocnemius lateralis (GL) in both legs. Electromyographic evaluation included compound muscle action potentials (CMAPs) recorded from the GM and GL of both legs. Clinical assessment of the spastic gastrocnemius muscle was performed with the Modified Ashworth Scale (MAS) and by measuring ankle dorsiflexion passive range of motion (PROM).

Results

Spastic muscle echo intensity was inversely associated with proximal (GM and GL: P=.002) and distal (GM and GL: P=.001) muscle thickness, pennation angle (GM: P< .001; GL: P=.01), CMAP (GM: P=.014; GL: P=.026), and ankle PROM (GM: P=.038; GL: P=.024). The pennation angle was directly associated with the proximal (GM and GL: P< .001) and distal (GM: P=.001; GL: P< .001) muscle thickness of the spastic gastrocnemius muscle. The MAS score was directly associated with muscle echo intensity (GM: P=.039; GL: P=.027) and inversely related to the pennation angle (GM and GL: P=.001) and proximal (GM: P=.016; GL: P=.009) and distal (GL: P=.006) muscle thickness of the spastic gastrocnemius.

Conclusions

Increased spastic muscle echo intensity was associated with reduced muscle thickness, posterior pennation angle, and CMAP amplitude in the gastrocnemius muscle. Building on previous evidence that these instrumental features are related to botulinum toxin response, these new findings may usefully inform spasticity treatment decisions.     

Interdisciplinary Cardiovascular and Neurologic Outpatient Rehabilitation in Patients Surviving Transient Ischemic Attack or Stroke With Minor or No Residual Deficits

Objective

To evaluate the feasibility and effectiveness of a comprehensive outpatient rehabilitation program combining secondary prevention and neurorehabilitation to improve vascular risk factors, neurologic functions, and health-related quality of life (HRQOL) in patients surviving a transient ischemic attack (TIA) or stroke with minor or no residual deficits.

Design

Prospective interventional single-center cohort study.

Setting

University hospital.

Participants

Consecutive consenting patients having sustained a TIA or stroke with 1 or more vascular risk factors (N=105) were included.

Interventions

Three-month hospital-based secondary prevention and neurorehabilitation outpatient program with therapeutic and educational sessions twice a week. Patients were evaluated at entry and program end.

Main Outcome Measures

Impact on vascular risk factors, neurological outcome, and HRQOL.

Results

A total of 105 patients entered the program and 95 patients completed it. Exercise capacity (P<.000), smoking status (P=.001), systolic (P=.001) and diastolic (P=.008) blood pressure, body mass index (P=.005), low-density lipoprotein cholesterol (P=.03), and triglycerides (P=.001) improved significantly. Furthermore, the 9-Hole-Peg-Test (P<.000), Six-minute Walking Test (P<.000), and One Leg Stand Test (P<.011) values as well as HRQOL improved significantly. The program could be easily integrated into an existing cardiovascular prevention and rehabilitation center and was feasible and highly accepted by patients.

Conclusions

Comprehensive combined cardiovascular and neurologic outpatient rehabilitation is feasible and effective to improve vascular risk factors, neurologic functions, and HRQOL in patients surviving TIA or stroke with minor or no residual deficits.     

Symptoms of Depression Over Time in Adults With Pediatric-Onset Spinal Cord Injury

Objective

To investigate the prevalence of depressive symptoms in adults with pediatric-onset spinal cord injury (SCI) and explore potential risk factors that may be associated with elevated symptoms.

Design

Longitudinal, cohort survey over a period of 2 to 9 years. Follow-up occurred approximately every year, a total of 868 interviews were conducted, and most participants contributed to at least 3 waves of data (72%; range, 2–8; mean, 4.34±2.16).

Setting

Community.

Participants

Adults (N=214; 133 men; mean age at first interview, 29.52±5.21y; range, 24–42y) who sustained an SCI prior to age 19 (mean age at injury, 13.93±4.37y; range, 0–18y). Participants tended to have complete injuries (71%) and tetraplegia (58%).

Interventions

Not applicable.

Main Outcome Measures

Participants completed measures assessing psychosocial functioning, physical independence, participation, and depression at each time point. Multilevel growth modeling analyses were used to explore depression symptoms across time.

Results

Depression symptoms at initial status were typically minimal (3.07±.24; 95% confidence interval, 2.6–3.54) but fluctuated significantly over time (P<.01). Several factors emerged as significant predictors of depressive symptoms in the final model, including less community participation (P<.01), incomplete injury (P=.02), hazardous drinking (P=.02), bladder incontinence (P=.01), and pain (P=.03). Within individuals, as bowel accidents (P<.01) and pain increased (P<.01), depression scores increased; however, marriage resulted in decreases in depression scores for individuals (P=.02).

Conclusions

These findings suggest that most patients with pediatric-onset SCI are psychologically resilient, but strategies to minimize secondary health complications and foster community participation and engagement should be considered.     

Functional Outcomes Associated With Adaptive Seating Interventions in Children and Youth With Wheeled Mobility Needs

Objective

To determine the parent-reported functional outcomes associated with adaptive seating devices for wheeled mobility devices used by young people aged 1 to 17 years.

Design

Longitudinal case series.

Setting

Homes of participating parents.

Participants

Parents (N=70, 63 mothers, 6 fathers, 1 grandmother) who had children with adaptive seating needs.

Intervention

Adaptive seating system for wheeled mobility devices.

Main Outcome Measure

Family Impact of Assistive Technology Scale for Adaptive Seating (FIATS-AS).

Results

All parents completed the FIATS-AS 4 times—2 times before and 2 times after their child received a new adaptive seating system. Mixed-design analysis of variance did not detect significant mean differences among the FIATS-AS scores measured at baseline and 2 and 8 months after receiving the seating system (F_2,134=.22, P=.81). However, the FIATS-AS detected a significant interaction between age cohort and interview time (F_4,134=4.5, P<.001, partial η²=.16). Post hoc testing confirmed that 8 months after receiving the seating system was associated with a large improvement in child and family functioning for children <4 years, maintenance of functioning for children between 4 and 12 years, and a moderate decline in functioning for youth between 13 and 17 years.

Conclusions

Adaptive seating interventions for wheeled mobility devices are associated with functional changes in the lives of children and their families that interact inversely with age. Future controlled longitudinal studies could provide further empirical evidence of functional changes in the lives of children and their families after the introduction and long-term use of specific adaptive seating interventions.     

Validation of the revised Bakas Caregiving Outcomes Scale in Greek caregivers of patients with advanced cancer receiving palliative radiotherapy

Purpose

Caregiver burden considerably affects the lives of families providing care to people with advanced cancer. The aim of this study was to validate the Greek translation of the revised Bakas Caregiving Outcomes Scale (BCOS) with a sample of informal caregivers of people with advanced cancer receiving outpatient palliative radiotherapy.

Methods

Following a formal “forward–backward” method to translate the original BCOS into Greek, the scale was administered to 100 consecutive family caregivers. Participants also completed the Greek Hospital Anxiety and Depression Scale (G-HADS) and five quality-of-life related linear analogue scale assessment (LASA) scales. Validity and reliability analyses were performed.

Results

The Cronbach’s α coefficient for the total BCOS score was 0.83. Test–retest reliability analysis in a subgroup of caregivers (n?=?40) revealed good short-term stability over a 2-week interval. Exploratory factor analysis generated a one-factor structure for the Greek translation, which was further confirmed through confirmatory factor analysis. Construct validity was supported through the scale’s high correlations with G-HADS anxiety (?0.524; p?<?0.001) and depression (?0.533; p?<?0.001) scores, and LASA quality of life scores (0.696; p?<?0.001). The BCOS discriminated well between groups of caregivers with different levels of quality of life. A total score of 52.5 offered high sensitivity (91 %) and specificity (86 %) in detecting highly burdened caregivers.

Conclusions

The Greek version of the BCOS is a psychometrically sound instrument that can be usefully implemented into clinical practice to identify family caregivers in need for support, and stimulate relevant research in our country.     

Comparing the Course of Mental Health Over the First Year After Stroke With Healthy Controls in Colombia,South America

Background

Stroke is a primary cause of death and disability in upper-middle–income countries such as Colombia. Given the lack of comprehensive rehabilitation for stroke patients in Colombia, there is a need to assess longitudinal mental health problems poststroke in this region.

Relationship Between Sleep,Pain, and Disability in Patients With Spinal Pathology

Objective

To characterize sleep and its relationship with disability and pain in patients with spine pathology.

Design

A survey study.

Setting

A university-based hospital spine clinic.

Participants

Subjects (N=121) with mixed-etiology spine pathology.

Interventions

Not applicable.

Main Outcome Measures

Self-reported disability (Oswestry Disability Index [ODI]), back and leg pain intensity, the effect of back or leg pain on function, and sleep (Pittsburgh Sleep Quality Index [PSQI]) assessments were completed.

Results

Severe disability was evident with a mean ODI ± SD of 54.9±14, with mean pain intensities ± SD of 50±30mm and 54±27mm of 100mm for the leg and back, respectively. The mean PSQI ± SD was 10.4±5.3, with 87% of participants scoring greater than the sleep-disordered threshold of 5. PSQI was correlated to ODI (r=.53, P<.001), and ODI without the sleep component (r=.47, P<.001). Six of the subscales of PSQI were all also significantly correlated to ODI (.25<r<.42, P<.05). Stepwise regression (ODI dependent variables; PSQI, pain intensity and function, age, body mass index as independent variables) was performed. PSQI was retained in the model along with 2 pain measures (r²=.50, P<.001). Substitution of the 7 subscales for the overall PSQI score revealed 2 subscales (sleep quality, use of sleep medications) as predictors of ODI (r²=.490, P<.001).

Conclusions

Despite its being intuitive that sleep disorders will be present in patients with spinal disorders, it was surprising that sleep quality was an independent predictor of disability along with pain. Furthermore, sleep quality is more closely correlated to disability than leg pain, which is the current focus of medical interventions.     

Assisted Movement With Proprioceptive Stimulation Reduces Impairment and Restores Function in Incomplete Spinal Cord Injury

Objective

To test whether treatment with assisted movement with enhanced sensation (AMES) using vibration to the antagonist muscle would reduce impairments and restore upper limb function in people with incomplete tetraplegia.

Design

Prospective, pre-post study.

Setting

Laboratory and rehabilitation hospital.

Participants

We recruited 15 arms from 10 individuals (8 men; mean age, 40.5y; mean years postspinal cord injury [SCI], 3) with chronic, incomplete tetraplegia.

Intervention

Two or three 20-minute sessions per week over 9 to 13 weeks (25 sessions total) on the AMES device, which combines repeated movement with targeted vibration to the antagonist muscle.

Main Outcome Measures

Strength and active motion tests on the AMES device; International Standards for the Neurological Classification of SCI (ISNCSCI) motor and sensory examinations; Modified Ashworth Scale (MAS); grasp and release test (GRT); Van Lieshout Test (VLT); and Capabilities of Upper Extremity questionnaire (CUE).

Results

The AMES strength test scores improved significantly in metacarpophalangeal flexion (P=.024) and extension (P=.007) and wrist flexion (P=.001) and extension (P<.000). The AMES active motion scores improved in the hand (P=.001) and wrist (P=.001). The MAS and ISNCSCI scores remained unchanged, whereas the GRT scores increased (P=.025). Post hoc analysis showed a trend from pre- to posttreatment (P=.068) and a significant change from pretreatment to 3-month follow-up (P=.046). There was no significant change in the VLT (P=.951) or the CUE (P=.164). Five of the 10 participants reported a return of sensation to the digits after the first, second, or third treatment session.

Conclusions

People with chronic, incomplete tetraplegia may experience improvements in impairments and function after treatment on a device combining assisted movement and proprioceptive stimulation. Further investigation is warranted.     

Additive Effect of Age on Disability for Individuals With Spinal Cord Injuries

Objective

To examine the additive effect of age on disability for adults with spinal cord injury (SCI).

Design

Prospective cohort study.

Setting

SCI Model Systems.

Participants

Individuals with SCI (median age at injury, 32y; range, 6–88y) with a discharge motor FIM score and at least 1 follow-up motor FIM score who also provided measures of other covariates (N=1660). Of the total sample, 79% were men, 72% were white, 16% had incomplete paraplegia, 33% had complete paraplegia, 30% had incomplete tetraplegia, and 21% had complete tetraplegia.

Interventions

Not applicable.

Main Outcome Measures

The primary study outcome was the motor subscale of the FIM. A mixed-models approach was used to examine the additive effect of age on disability for individuals with SCI.

Results

When controlling for motor FIM at discharge from rehabilitation, level and severity of injury, age at injury, sex, race, and the age × time interaction were not significant (P=.07). Age at the time of SCI was significantly associated with motor FIM (F_1,238=22.49, P<.001). Two sensitivity analyses found significant interactions for both age × time (P=.03, P=.02) and age × time-square (P=.01, P=.006) models. Trajectory of motor FIM scores is moderated slightly by age at the time of injury. The older participants were at the time of injury, the greater the curvature and the more rapid decline were found in later years.

Conclusions

These findings indicate that age moderately influences disability for some individuals with SCI: the older the age at the time of injury, the greater the influence age has on disability. The findings serve as an important empirical foundation for the evaluation and development of interventions designed to augment accelerated aging experienced by individuals with SCI.     

Differential Effects of Cardiovascular and Resistance Exercise on Functional Mobility in Individuals With Advanced Cancer: A Randomized Trial

Objective

To compare the effects of resistance and cardiovascular exercise on functional mobility in individuals with advanced cancer.

Design

Prospective, 2-group pretest-posttest pilot study with randomization to either resistance or cardiovascular exercise mode.

Setting

Comprehensive community cancer center and a hospital-based fitness facility.

Participants

Volunteer sample of individuals (N=66; 30 men; 36 women; mean age, 62y) with advanced cancer recruited through the cancer center, palliative care service, rehabilitation department, and a local hospice.

Interventions

Ten weeks of individualized resistance or cardiovascular exercise, prescribed and monitored by oncology-trained exercise personnel.

Main Outcome Measures

Functional mobility was assessed using the Short Physical Performance Battery (SPPB); self-reported pain and fatigue were assessed secondarily using visual analog scales. Data were analyzed using a split plot 2×2 analysis of variance (α=.05).

Results

Fifty-two patients (78.8%) completed the study: 23 (67.7%) of 34 patients in the resistance arm and 29 (90.6%) of 32 patients in the cardiovascular arm. No participant withdrew because of study adverse events. Ten-week outcomes (n=52) included a significant increase in SPPB total score (P<.001), increase in gait speed (P=.001), and reduction in fatigue (P=.05). Although cardiovascular exercise participants had a modestly greater improvement in SPPB total score than resistance training participants (F_1,49=4.21, P=.045), the difference was not confirmed in a subsequent intention-to-treat analysis (N=66).

Conclusions

Individuals with advanced cancer appear to benefit from exercise for improving functional mobility. Neither resistance nor cardiovascular exercise appeared to have a strong differential effect on outcome.     

Informal caregiver strain,preference and satisfaction in hospital-at-home and usual hospital care for COPD exacerbations: Results of a randomised controlled trial

Background

Informal caregivers play an important role in hospital-at-home schemes. However they may increase their burden, especially chronic diseases, like COPD. In the absence of clear differences in effectiveness and cost-effectiveness between hospital-at-home and usual hospital care, informal caregiver preferences play an important role. This study investigated informal caregiver strain, satisfaction and preferences for place of treatment with a community-based hospital-at-homes scheme for COPD exacerbations.

Method

The study was part of a larger randomised controlled trial. By randomisation, patients were allocated to usual hospital care or hospital-at-home, which included discharge at day 4 of admission, followed by home treatment with homes visits by community nurses until day 7 of treatment. Patients allocated to usual hospital care received care as usual in the hospital and were discharged at day 7. Patients were asked if they had an informal caregiver and who this was. Patients and their caregivers were followed for 90 days. Informal caregiver strain was assessed with the caregiver strain index. Satisfaction and preference were assessed using questionnaires. All measurements were performed at the end of the 7-day treatment and the end of the 90-days follow-up.

Findings

Of the 139 patients, 124 had an informal caregiver, of whom three-quarter was the patients’ spouse. There was no significant difference in caregiver strain between hospital-at-home and usual hospital care at both time points (mean difference at T + 4 days 0.47 95% CI −0.96 to 1.91, p = 0.514; mean difference at T + 90 days 0.36 95% CI −1.85 to 1.35, p = 0.634). At the end of the 7-day treatment, 33% (N = 15) of caregivers of patients allocated to hospital treatment and 71% (N = 37) of caregivers of patients allocated to home treatment preferred home treatment, if they could choose. Caregivers were satisfied with the treatment the patient received within hospital-at-home.

Conclusion

There were no differences in caregiver strain between the community-based hospital-at-home scheme and usual hospital care. Most caregivers were satisfied with the treatment. In addition to other outcomes, our results support the wider implementation of hospital-at-home for COPD exacerbations.     

Comparative Impacts of Tai Chi,Balance Training,and a Specially-Designed Yoga Program on Balance in Older Fallers

Objective

To compare the effect of a custom-designed yoga program with 2 other balance training programs.

Design

Randomized controlled trial.

Setting

Research laboratory.

Participants

A group of older adults (N=39; mean age, 74.15±6.99y) with a history of falling.

Interventions

Three different exercise interventions (Tai Chi, standard balance training, yoga) were given for 12 weeks.

Main Outcome Measures

Balance performance was examined during pre- and posttest using field tests, including the 8-foot up-and-go test, 1-leg stance, functional reach, and usual and maximal walking speed. The static and dynamic balances were also assessed by postural sway and dynamic posturography, respectively.

Results

Training produced significant improvements in all field tests (P<.005), but group difference and time × group interaction were not detected. For postural sway, significant decreases in the area of the center of pressure with eyes open (P=.001) and eyes closed (P=.002) were detected after training. For eyes open, maximum medial-lateral velocity significantly decreased for the sample (P=.013). For eyes closed, medial-lateral displacement decreased for Tai Chi (P<.01). For dynamic posturography, significant improvements in overall score (P=.001), time on the test (P=.006), and 2 linear measures in lateral (P=.001) and anterior-posterior (P<.001) directions were seen for the sample.

Conclusions

Yoga was as effective as Tai Chi and standard balance training for improving postural stability and may offer an alternative to more traditional programs.     

Evaluation of Activity Limitation in Patients With Idiopathic Pulmonary Fibrosis Grouped According to Medical Research Council Dyspnea Grade

Objective

To investigate the relations between Medical Research Council (MRC) dyspnea grade and peripheral muscle force, activities of daily living (ADL) performance, health status, lung function, and exercise capacity in subjects with idiopathic pulmonary fibrosis (IPF).

Design

Prospective cross-sectional observational study.

Setting

University hospital.

Participants

Subjects with IPF (N=65, 46 men) in a stable clinical state with a mean age of 68±7 years.

Interventions

Not applicable.

Main Outcome Measures

Right ventricular systolic pressure (RVSP) via transthoracic echocardiography, pulmonary function, isometric quadriceps force (QF) and handgrip force (HF), 6-minute walk distance (6MWD), ADL score, and health status (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]) were assessed and compared between subjects grouped according to MRC grade.

Results

Of the participants, 16 were in MRC grade 2, 17 were in MRC grade 3, 17 were in MRC grade 4, and 15 were in MRC grade 5. RVSP, pulmonary function, QF, HF, 6MWD, ADL, and SF-36 scores decreased with increasing MRC grade (all P<.001). All measures were lower (P<.05) in subjects with grades 4 and 5 than subjects with grades 2 and 3. Strong associations were found between MRC grade and 6MWD (ρ=−.89, P=.001) and ADL score (ρ=−.82, P=.001). MRC grade was also associated with RVSP, pulmonary function, QF, and HF (all ρ≥.56, P=.001).

Conclusions

The MRC dyspnea scale provides a simple and useful method of categorizing individuals with IPF with respect to their activity limitation and may assist in understanding the impact of IPF on an individual.     

High-Level Mobility in Chronic Traumatic Brain Injury and Its Relationship With Clinical Variables and Magnetic Resonance Imaging Findings in the Acute Phase

Objectives

To compare high-level mobility in individuals with chronic moderate-to-severe traumatic brain injury (TBI) with matched healthy controls, and to investigate whether clinical variables and magnetic resonance imaging (MRI) findings in the acute phase can predict high-level motor performance in the chronic phase.

Design

A longitudinal follow-up study.

Setting

A level 1 trauma center.

Participants

Individuals (N=136) with chronic TBI (n=65) and healthy matched peers (n=71).

Interventions

Not applicable.

Main Outcome Measures

High-Level Mobility Assessment Tool (HiMAT) and the revised version of the HiMAT performed at a mean of 2.8 years (range, 1.5–5.4y) after injury.

Results

Participants with chronic TBI had a mean HiMAT score of 42.7 (95% confidence interval [CI], 40.2–45.2) compared with 47.7 (95% CI, 46.1–49.2) in the control group (P<.01). Group differences were also evident using the revised HiMAT (P<.01). Acute-phase clinical variables and MRI findings explained 58.8% of the variance in the HiMAT score (P<.001) and 59.9% in the revised HiMAT score (P<.001). Lower HiMAT scores were associated with female sex (P=.031), higher age at injury (P<.001), motor vehicle collisions (P=.030), and posttraumatic amnesia >7 days (P=.048). There was a tendency toward an association between lower scores and diffuse axonal injury in the brainstem (P=.075).

Conclusions

High-level mobility was reduced in participants with chronic, either moderate or severe TBI compared with matched peers. Clinical variables in the acute phase were significantly associated with high-level mobility performance in participants with TBI, but the role of early MRI findings needs to be further investigated. The findings of this study suggest that the clinical variables in the acute phase may be useful in predicting high-level mobility outcome in the chronic phase.