Anxiety and Depression Associated With Caregiver Burden in Caregivers of Stroke Survivors With Spasticity

Objective

To investigate the relationship between anxiety/depression and caregiver burden in informal caregivers of stroke survivors with spasticity.

Design

Data were collected via online surveys from informal caregivers 18 years or older who cared for stroke survivors.

Setting

Internet-based survey.

Participants

2007 through 2009 U.S. National Health and Wellness Survey database or Lightspeed Research general panel respondents (N=153).

Interventions

Not applicable.

Main Outcome Measures

Anxiety and depression were self-reported by the caregiver as a physician diagnosis. Depression severity was measured by the Patient Health Questionnaire-9 (PHQ-9). Caregiver burden was measured by the Oberst Caregiving Burden Scale (OCBS) and the Bakas Caregiving Outcomes Scale (BCOS). Logistic regression analyses were conducted with anxiety, depression, and the PHQ-9 depression severity categories as a result of each caregiver burden scale.

Results

Data were analyzed for 153 informal caregivers; they were mostly women (70.6%) and white (78.4%), with a mean age of 51.6 years. For every 1-point increase in the OCBS Difficulty Scale, the odds of anxiety or depression were 2.57 times as great (P<.001) and 1.88 times as great (P=.007), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 2.48 times as great (P<.001). For every 1-point decrease in the BCOS, the odds of anxiety or depression were 2.43 times as great (P<.001) and 2.27 times as great (P=.002), respectively. The odds of PHQ-9 severe depression versus all other categories combined were 4.55 times as great (P<.001).

Conclusions

As caregiver burden increases, caregivers are more likely to have anxiety and depression. Depression severity also increases. Providing treatment to stroke survivors with spasticity that lessens the time and more importantly, the difficulty of caregiving may lead to a reduction in caregiver anxiety and depression.     

Reducing pain in patients undergoing cardiac surgery after implementation of a quality improvement postoperative pain treatment program

Purpose

The aim of this study was to test the effectiveness of a quality improvement postoperative pain treatment program after cardiac surgery.

Materials and Methods

This was a prospective, quasiexperimental study using nonequivalent groups comprising 3 periods: baseline (group baseline), implementation of the algorithm for acute pain management, and reassessment (group reassessment). Inclusion of 133 patients after elective cardiac surgery at an 18-bed surgical intensive care unit (SICU) at a Swiss university hospital. The algorithm was implemented by training, pocket guidelines, regular audits, and feedback. The implementation period was completed when the adherence to 2 of 3 process indicators attained at least 70% over 2 months. Visual analog scales (VAS) for pain, morphine consumption, pain perception, and sleep quality were assessed during stay in SICU and after 1 month and 6 months.

Results

The assessment included 79 patients at baseline and 54 in the reassessment periods. Pain intensity at rest decreased from 2.7 ± 1.4 to 2.2 ± 1.4 cm (VAS; P = .008). Retrospective perception of pain intensity at rest decreased from 3.8 ± 2.2 to 2.6 ± 1.8 (P = .004). The proportion of patients with no pain or often without pain increased from 11% to 37% (P = .005). The number of patients with sleep disturbances decreased from 68% to 35% (P = .012). No differences were observed at 1 and 6 months postoperatively.

Conclusions

After algorithm implementation in the SICU, pain intensity at rest decreased and quality of sleep improved.     

Long-Term Disability and Survival in Traumatic Brain Injury: Results From the National Institute on Disability and Rehabilitation Research Model Systems

Objectives

To document long-term survival in 1-year survivors of traumatic brain injury (TBI); to compare the use of the Disability Rating Scale (DRS) and FIM as factors in the estimation of survival probabilities; and to investigate the effect of time since injury and secular trends in mortality.

Design

Cohort study of 1-year survivors of TBI followed up to 20 years postinjury. Statistical methods include standardized mortality ratio, Kaplan-Meier survival curve, proportional hazards regression, and person-year logistic regression.

Setting

Postdischarge from rehabilitation units.

Participants

Population-based sample of persons (N=7228) who were admitted to a TBI Model Systems facility and survived at least 1 year postinjury. These persons contributed 32,505 person-years, with 537 deaths, over the 1989 to 2011 study period.

Interventions

Not applicable.

Main Outcome Measure

Survival.

Results

Survival was poorer than that of the general population (standardized mortality ratio=2.1; 95% confidence interval, 1.9–2.3). Age, sex, and functional disability were significant risk factors for mortality (P<.001). FIM- and DRS-based proportional hazards survival models had comparable predictive performance (C index: .80 vs .80; Akaike information criterion: 11,005 vs 11,015). Time since injury and current calendar year were not significant predictors of long-term survival (both P>.05).

Conclusions

Long-term survival prognosis in TBI depends on age, sex, and disability. FIM and DRS are useful prognostic measures with comparable statistical performance. Age- and disability-specific mortality rates in TBI have not declined over the last 20 years. A survival prognosis calculator is available online (http://www.LifeExpectancy.org/tbims.shtml).     

Health-Related Quality of Life 3 Years After Moderate to Severe Traumatic Brain Injury: A Prospective Cohort Study

Objectives

To evaluate the time course of health-related quality of life (HRQoL) after moderate to severe traumatic brain injury (TBI) and to identify its predictors.

Design

Prospective cohort study with follow-up measurements at 3, 6, 12, 18, 24, and 36 months after TBI.

Setting

Patients with moderate to severe TBI discharged from 3 level-1 trauma centers.

Participants

Patients (N=97, 72% men) with a mean age ± SD of 32.8±13.0 years (range, 18–65y), hospitalized with moderate (23%) or severe (77%) TBI.

Interventions

Not applicable.

Main Outcome Measures

HRQoL was measured with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), functional outcomes with the Glasgow Outcome Scale (GOS), Barthel Index, FIM, and Functional Assessment Measure, and mood with the Wimbledon Self-Report Scale.

Results

The SF-36 domains showed significant improvement over time for Physical Functioning (P<.001), Role Physical (P<.001), Bodily Pain (P<.001), Social Functioning (P<.001), and Role Emotional (P=.024), but not for General Health (P=.263), Vitality (P=.530), and Mental Health (P=.138). Over time there was significant improvement in the Physical Component Summary (PCS) score, whereas the Mental Component Summary (MCS) score remained stable. At 3-year follow-up, HRQoL of patients with TBI was the same as that in the Dutch normative population. Time after TBI, hospital length of stay (LOS), FIM, and GOS were independent predictors of the PCS, whereas LOS and mood were predictors of the MCS.

Conclusions

After TBI, the physical component of HRQoL showed significant improvement over time, whereas the mental component remained stable. Problems of disease awareness seem to play a role in self-reported mental HRQoL. After TBI, mood status is a better predictor of the mental component of HRQoL than functional outcome, implying that mood should be closely monitored during and after rehabilitation.     

Long-term effects of medical exercise therapy in patients with patellofemoral pain syndrome: Results from a single-blinded randomized controlled trial with 12 months follow-up

Objectives

To evaluate the long-term effect of high-dose, high-repetition medical exercise therapy (MET) in patients with patellofemoral pain syndrome (PFPS).

Design

Follow-up study one year after completion of a randomized, controlled trial.

Setting

Follow-up testing in the primary healthcare physiotherapy clinics, where intervention was undertaken.

Participants

Twenty-eight patients with PFPS completed follow-up testing, fourteen in each group.

Interventions

The groups received three treatments per week for 12 weeks: high-dose, high-repetition MET for the experimental group, and low-dose, low-repetition exercise therapy for the control group.

Main outcome measures

Pain measured using a visual analogue scale (VAS: 0–10 cm), and function measured using a step-down test (numbers of completed step-downs in 30 seconds) and the modified Functional Index Questionnaire (FIQ: 0 points indicates maximal disability, 16 points no disability).

Results

At baseline there were no differences between groups. After intervention, there were statistically significant (p < 0.05) and clinically important differences between groups for all outcome parameters, also when adjusting for gender and duration of symptoms: −1.6 for mean pain [95% confidence interval (CI) −2.4 to −0.8], 6.5 for step-down test (95% CI 3.8 to 9.2), and 3.1 for FIQ (95% CI 1.2 to 5.0). At follow-up the differences between groups were maintained and even increased for mean pain and step-down with significant differences (p < 0.05) between groups; −1.8 for mean pain (95% CI: −2.7 to −1.0) and 4.5 for step-down test (95%CI: 2.4 to 6.5). The difference between groups for FIQ at follow-up: 1.1 (95% CI: −1.1 to 3.3).

Conclusion

There appear to be long-term effects of high-dose, high-repetition MET in patients with PFPS with respect to pain and functional outcomes. One year after completed intervention the experimental group has continued to improve, while the control group has relapsed.Registered on http://www.clinicaltrials.gov (identifier: NCT01290705).     

Participation in and Impact of a Depression Care Management Program Targeting Low-Income Minority Patients in an Urban Community-Based Clinic

Background

African American people experience disproportionately higher rates of chronic depression, and among those affected, the condition is less likely to be detected and treated than in non-Hispanic white people.

Objective

To address this disparity in our primary care clinic, we introduced a validated framework for detecting and managing depression.

Methods

Over a 5-year period, there were 146 patients diagnosed as having depression and enrolled in a depression care management program. We evaluated the feasibility and effectiveness of that program using baseline and follow-up screening data from the Patient Health Questionnaire-9.

Results

The mean baseline severity score of 20.60 was reduced to 15.89 at 6 months (P < 0.001) and to 16.62 at 12 months. Patients achieved their best score, a mean of 12.93, 10.14 months after baseline (P < 0.001). The last mean severity score, after 15.47 months, was 14.60, a significant difference compared with baseline (P < 0.001). Although baseline severity scores for both groups were similar (P = 0.534), patients who remained engaged with the program demonstrated better scores and achieved greater severity score reductions from baseline to the last measure (P < 0.001). This study did not find any differences between the sexes when comparing PHQ-9 scores at baseline (P = 0.074), 6 months (P = 0.303), and 12 months (P = 0.429) and best (P = 0.875) and last (P = 0.640) scores.

Conclusions

Most of the improvement was witnessed in the first 10 months of treatment. Patients with more medical comorbidities participated longer in the study than patients with fewer comorbidities. Further research could elicit the relationship between improvement in mental health and medical conditions.     

Posterolateral Hip Muscle Strengthening Versus Quadriceps Strengthening for Patellofemoral Pain: A Comparative Control Trial

Objective

To compare the efficacy of posterolateral hip muscle strengthening versus quadriceps strengthening in reducing pain and improving health status in persons with patellofemoral pain (PFP).

Design

Comparative control trial.

Setting

Rehabilitation facility.

Participants

Persons with a diagnosis of PFP (N=36; 18 men, 18 women).

Interventions

Patients were alternately assigned to a posterolateral hip muscle strengthening group (9 men and 9 women) or a quadriceps strengthening group (9 men and 9 women). The posterolateral hip muscle strengthening group performed hip abductor and external rotator strengthening exercises, whereas the quadriceps strengthening group performed quadriceps strengthening exercises (3 times a week for 8wk).

Main Outcome Measures

Pain (visual analog scale [VAS]) and health status (Western Ontario McMaster Universities Osteoarthritis Index [WOMAC]) were assessed at baseline, postintervention, and 6-month follow-up.

Results

Significant improvements in VAS and WOMAC scores were observed in both groups from baseline to postintervention and baseline to 6-month follow-up (P<.001). Improvements in VAS and WOMAC scores in the posterolateral hip exercise group were superior to those in the quadriceps exercise group postintervention and at 6-month follow-up (P<.05).

Conclusions

Although both intervention programs resulted in decreased pain and improved function in persons with PFP, outcomes in the posterolateral hip exercise group were superior to the quadriceps exercise group. The superior outcomes obtained in the posterolateral hip exercise group were maintained 6 months postintervention.     

Intravenous Lidocaine for the Emergency Department Treatment of Acute Radicular Low Back Pain,a Randomized Controlled Trial

Background

Acute radicular back pain is a frequent complaint of patients presenting to the Emergency Department.

Study Objective

Determine the efficacy of intravenous lidocaine when compared to ketorolac for the treatment of acute radicular low back pain.

Methods

Randomized double-blind study of 41 patients aged 18–55 years presenting with acute radicular low back pain. Patients were randomized to receive either 100 mg lidocaine or 30 mg ketorolac intravenously over 2 min. A 100-mm visual analog scale (VAS) was used to assess pain at Time 0 (baseline), and 20, 40, and 60 minutes. Changes in [median] VAS scores were compared over time (within groups) by the signed-rank test and between groups by the rank-sum test. A 5-point Pain Relief Scale (PRS) was administered at the conclusion of the study (60 min) and again at 1 week by telephone follow-up; [median] scores were compared between groups by rank-sum.

Results

Forty-four patients were recruited; 41 completed the study (21 lidocaine, 20 ketorolac). Initial VAS scores were not significantly different between the lidocaine and ketorolac groups (83; 95% confidence interval [CI] 74–98 vs. 79; 95% CI 64–94; p = 0.278). Median VAS scores from baseline to 60 min significantly declined in both groups (lidocaine [8; 95% CI 0–23; p = 0.003]; ketorolac [14; 95% CI 0–28; p = 0.007]), with no significant difference in the degree of reduction between groups (p = 0.835). Rescue medication was required by 67% receiving lidocaine, compared to 50% receiving ketorolac. No significant change in PRS between groups was found at the conclusion or at the follow-up.

Conclusion

Intravenous lidocaine failed to clinically alleviate the pain associated with acute radicular low back pain.     

Predictors of Follow-Up Completeness in Longitudinal Research on Traumatic Brain Injury: Findings From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Program

Objective

To identify baseline participant variables in the domains of demographics, medical/psychosocial history, injury characteristics, and postinjury functional status associated with longitudinal follow-up completeness in persons with traumatic brain injury (TBI) using the TBI Model Systems (TBIMS) National Database (NDB).

Design

Exhaustive chi-square automatic interaction detection was used to identify factors that classified participants according to level of follow-up completeness.

Setting

Retrospective analysis of a multi-center longitudinal database.

Participants

Individuals (N=8249) enrolled in the TBIMS NDB between 1989 and 2009 who were eligible for at least the first (year 1) follow-up up to the fifth (year 15) follow-up.

Interventions

None.

Main Outcome Measures

Follow-up completeness as defined by 6 different longitudinal response patterns (LRPs): completing all follow-ups, wave nonresponse, dropping out, completing no follow-ups without formally withdrawing, formally withdrawing before completing any follow-ups, and formally withdrawing after completing some follow-ups.

Results

Completing all follow-ups was associated with higher levels of education, living with parents or others, and having acute care payer data entered in the NDB. Subgroups more vulnerable to loss to follow-up (LTFU) included those with less education, racial/ethnic minority backgrounds, those with better motor functioning on rehabilitation discharge, and those for whom baseline data on education, employment, and acute care payer were not collected. No subgroups were found to be more likely to have the LRPs of dropping out or formal withdrawal.

Conclusions

These data identify subgroups in which retention strategies beyond those most commonly used might reduce LTFU in longitudinal studies of persons with TBI, such as the TBIMS, and suggest future investigations into factors associated with missing baseline data.     

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.     

Effect of Interferential Current Stimulation in Management of Hemiplegic Shoulder Pain

Objective

To study the immediate effects of interferential current stimulation (IFC) on shoulder pain and pain-free passive range of motion (PROM) of the shoulder in people with hemiplegic shoulder pain (HSP).

Design

Double-blind, placebo-controlled clinical trial.

Setting

Institutional physical therapy clinic, neurologic rehabilitation center.

Participants

A population-based sample of people with HSP (N=30) was recruited.

Intervention

Participants were divided into 2 groups—an IFC group and a placebo group—by using a match-paired method (age, sex, and Brunnstrom motor recovery stage). In the IFC group, participants received IFC for 20 minutes with an amplitude-modulated frequency at 100Hz in vector mode. The current intensity was increased until the participants felt a strong tingling sensation.

Main Outcome Measures

Pain intensity and pain-free PROM of the shoulder until the onset of pain were measured at baseline and immediately after treatment.

Results

Participants reported a greater reduction in pain during the most painful movement after treatment with IFC than with placebo (P<.05). The IFC group showed a greater improvement in posttreatment pain-free PROM than the placebo group in shoulder flexion (P<.01), abduction (P<.01), internal rotation (P<.01), and external rotation (P<.01).

Conclusions

This study provides evidence that IFC is effective for the relief of pain during movement and also increases the pain-free PROM of the shoulder in people with HSP.     

Effectiveness of Home Exercise on Pain,Function, and Strength of Manual Wheelchair Users With Spinal Cord Injury: A High-Dose Shoulder Program With Telerehabilitation

Objective

To test the effectiveness of a high-dose home exercise/telerehabilitation program for manual wheelchair users who have a spinal cord injury (SCI) by determining whether the intervention would reduce pain and increase function, as we hypothesized.

Design

A pre-post trial with outcomes measured at 3 time points: baseline, postintervention (12wk), and follow-up (>24 wk).

Setting

Subjects performed an exercise program at their homes using telerehabilitation for therapist monitoring of technique and exercise advancement. Baseline and postintervention data were collected at a motion analysis laboratory in a tertiary medical center.

Participants

A convenience sample of manual wheelchair users (N=16, 3 women; average age, 41y; average time in a wheelchair, 16y) with shoulder pain (average pain duration, 9y) and mechanical impingement signs on physical examination.

Interventions

A 12-week home exercise program of rotator cuff and scapular stabilization exercises was given to each participant. The program included a high dose of 3 sets of 30 repetitions, 3 times weekly, and regular physical therapist supervision via videoconferencing.

Main Outcome Measures

Primary outcomes of pain and function were measured with the Wheelchair User's Shoulder Pain Index (WUSPI), Disabilities of Arm, Shoulder, and Hand (DASH) Index, and Shoulder Rating Questionnaire (SRQ). Secondary outcomes of strength were measured with isometric strength tests of scapulothoracic and glenohumeral muscles, and a static fatigue test of the lower trapezius.

Results

Pain was reduced and function improved after the intervention. There was a significant main effect for pain and function between the 3 time points based on the Friedman signed-ranked test, WUSPI (χ²₂=5.10, P=.014), DASH Index (χ²₂=5.41, P=.012), and SRQ (χ²₂=23.71, P≤.001). Wilcoxon signed-rank tests demonstrated that isometric strength measurements of the serratus anterior and scapular retractors increased after the exercise intervention ([t=2.42, P=.04] and [t=4.67, P=.003], respectively). Muscle impulse produced by the lower trapezius during a fatigue task also improved (t=2.2, P=.02). No differences were measured in isometric strength for the lower trapezius, glenohumeral rotators, and abductors between the baseline and 12-week time points.

Conclusions

A high-dose scapular stabilizer and rotator cuff strengthening program using telerehabilitation for supervision holds promise for shoulder pain treatment in manual wheelchair users with SCI. Additional work is needed to determine the effectiveness compared with other interventions, as well as the potential for earlier intervention to prevent development of shoulder pain.     

Functional Outcomes in Traumatic Disorders of Consciousness: 5-Year Outcomes From the National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems

Objective

To characterize the 5-year outcomes of patients with traumatic brain injury (TBI) not following commands when admitted to acute inpatient rehabilitation.

Design

Secondary analysis of prospectively collected data from the National Institute on Disability and Rehabilitation Research–funded Traumatic Brain Injury Model Systems (TBIMS).

Setting

Inpatient rehabilitation hospitals participating in the TBIMS program.

Participants

Patients (N=108) with TBI not following commands at admission to acute inpatient rehabilitation were divided into 2 groups (early recovery: followed commands before discharge [n=72]; late recovery: did not follow commands before discharge [n=36]).

Interventions

Not applicable.

Main Outcome Measures

FIM items.

Results

For the early recovery group, depending on the FIM item, 8% to 21% of patients were functioning independently at discharge, increasing to 56% to 85% by 5 years postinjury. The proportion functioning independently increased from discharge to 1 year, 1 to 2 years, and 2 to 5 years. In the late recovery group, depending on the FIM item, 19% to 36% of patients were functioning independently by 5 years postinjury. The proportion of independent patients increased significantly from discharge to 1 year and from 1 to 2 years, but not from 2 to 5 years.

Conclusions

Substantial proportions of patients admitted to acute inpatient rehabilitation before following commands recover independent functioning over as long as 5 years, particularly if they begin to follow commands before hospital discharge.     

Education Attenuates the Negative Impact of Traumatic Brain Injury on Cognitive Status

Objective

To investigate whether the cognitive reserve hypothesis helps to explain differential cognitive impairment among survivors of traumatic brain injury (TBI), whereby survivors with greater intellectual enrichment (estimated with education) are less vulnerable to cognitive impairment.

Design

Cross-sectional study.

Setting

Medical rehabilitation research center.

Participants

Survivors of moderate or severe TBI (n=44) and healthy controls (n=36).

Interventions

Not applicable.

Main Outcome Measures

Intellectual enrichment was estimated with educational attainment. Group was defined as TBI or healthy control. Current cognitive status (processing speed, working memory, episodic memory) was evaluated with neuropsychological tasks.

Results

TBI survivors exhibited worse cognitive status than healthy persons (P<.001), and education was positively correlated with cognitive status in TBI survivors (r=.54, P<.001). Most importantly, regression analysis revealed an interaction between group and education (R² change=.036, P=.004), whereas higher education attenuated the negative impact of TBI on cognitive status. TBI survivors with lower education performed much worse than matched healthy persons, but this TBI-related performance discrepancy was attenuated at higher levels of education.

Conclusions

Higher intellectual enrichment (estimated with education) reduces the negative effect of TBI on cognitive outcomes, thereby supporting the cognitive reserve hypothesis in persons with TBI. Future work is necessary to investigate whether intellectual enrichment can build cognitive reserve as a rehabilitative intervention in survivors of TBI.     

Gene expression profiles of fatigued fibromyalgia patients with different categories of pain and catastrophizing: A preliminary report

Background

Fibromyalgia (FM) is a chronic condition characterized by diffused musculoskeletal pain and overwhelming fatigue.

Purpose

To compare the gene expression profiles of fatigued FM women with different levels of pain and catastrophizing.

Methods

Nine women with FM enrolled in an active Medstar Research Institute protocol were included in the gene expression analyses of peripheral blood RNA via Affymetrix GeneChip Human Genome U133 Plus 2.0 array (Santa Clara, CA). Scores from Brief Pain Inventory, Pain Catastrophizing Scale, and Multidimensional Fatigue Inventory categorized the nine participants into pain (high, n = 3; low, n = 6) and catastrophizing groups (high, n = 5; low, n = 4).

Discussion

Differential expression of 107 genes between the high and low pain groups and 139 genes between the high and low catastrophizing groups (over 2.0-fold change, p < .05) were observed. Network analyses showed interferon signaling and interferon regulatory activation factor pathways distinguished between the pain groups whereas dendritic cell maturation delineated between the catastrophizing groups.

Conclusion

Findings provide preliminary evidence that specific physiological pathways may possibly delineate pain and catastrophizing mechanisms. Further investigation via the use of a larger and more homogenous sample is warranted.     

Association Between Disease-Specific Quality of Life and Magnetic Resonance Imaging Outcomes in a Clinical Trial of Prolotherapy for Knee Osteoarthritis

Objective

To assess the relation between knee osteoarthritis (KOA)-specific quality of life (QOL) and intra-articular cartilage volume (CV) in participants treated with prolotherapy. KOA is characterized by CV loss and multifactorial pain. Prolotherapy is an injection therapy reported to improve KOA-related QOL to a greater extent than blinded saline injections and at-home exercise, but its mechanism of action is unclear.

Design

Two-arm (prolotherapy, control), partially blinded, controlled trial.

Setting

Outpatient.

Participants

Adults with ≥3 months of symptomatic KOA (N=37).

Interventions

Prolotherapy: 5 monthly injection sessions; Control: blinded saline injections or at-home exercise.

Main Outcome Measures

Primary: KOA-specific QOL scores (baseline, 5, 9, 12, 26, and 52wk; Western Ontario and McMaster University Osteoarthritis Index). Secondary: KOA-specific pain, stiffness, function (Western Ontario McMaster University Osteoarthritis Index subscales), and magnetic resonance imaging–assessed CV (baseline, 52wk).

Results

Knee-specific QOL improvement among prolotherapy participants exceeded that among controls (17.6±3.2 points vs 8.6±5.0 points; P=.05) at 52 weeks. Both groups lost CV over time (P<.05); no between-group differences were noted (P=.98). While prolotherapy participants lost CV at varying rates, those who lost the least CV (“stable CV”) had the greatest improvement in pain scores. Among prolotherapy participants, but not control participants, the change in CV and the change in pain (but not stiffness or function) scores were correlated; each 1% CV loss was associated with 2.7% less improvement in pain score (P<.05).

Conclusions

Prolotherapy resulted in safe, substantial improvement in KOA-specific QOL compared with control over 52 weeks. Among prolotherapy participants, but not controls, magnetic resonance imaging–assessed CV change (CV stability) predicted pain severity score change, suggesting that prolotherapy may have a pain-specific disease-modifying effect. Further research is warranted.     

Correlation Between Voluntary Cough and Laryngeal Cough Reflex Flows in Patients With Traumatic Brain Injury

Objective

To correlate voluntary cough and laryngeal cough reflex (LCR) flows in patients with traumatic brain injury (TBI).

Design

Cross-sectional study.

Setting

University rehabilitation hospital.

Participants

Patients with TBI (n=25) and healthy controls (n=48).

Interventions

Not applicable.

Main Outcome Measures

Peak cough flows (PCFs) and LCR flows were measured using a peak flow meter at the oral-nasal interface. The largest value of 3 attempts was recorded for PCF and LCR, respectively. LCR was elicited by 20% solution of pharmaceutic-grade citric acid dissolved in sterile .15M NaCl solution that was inhaled from a nebulizer.

Results

PCF was 447.4±99.0L/min in the control group and 211.7±58.2L/min in the patient group. LCR was 209.2±63.8L/min in the control group and 170.0±59.7L/min in the patient group. Both PCF (P=.000) and LCR (P=.013) were significantly reduced in patients with TBI compared to that of the control group. LCR was strongly related to the PCF in both control (R=.645; P=.000) and patient (R=.711; P=.000) groups.

Conclusions

As LCR can be measured as a numerical value and significantly correlates with PCF, LCR can be used to estimate cough ability of patients with TBI who cannot cooperate with PCF measurement.     

Negative Affect and Sleep Disturbance May Be Associated With Response to Epidural Steroid Injections for Spine-Related Pain

Objective

To describe whether negative affect and sleep impairment are associated with the clinical effect of epidural steroid injections (ESIs) for low back pain.

Design

Observational study; patients were evaluated before ESI and 1 and 3 months after ESI.

Setting

Spine center and related treatment sites.

Participants

Participants (N=158) seeking treatment for low back pain with or without radiculopathy.

Intervention

ESI for low back pain with or without radiculopathy.

Main Outcome Measures

We assessed the dependent (global pain severity for back and leg pain, pain behavior, pain interference) and independent variables (depression, sleep disturbance, and covariates of back pain response) with the Patient-Reported Outcome Measurement Information System (PROMIS) and legacy measures. Outcome was assessed cross-sectionally using multiple regression and longitudinally with path analysis.

Results

After 1 month, sleep disturbance was the only predictor for the global ratings of improvement in back pain (R²=16.8%) and leg pain (R²=11.4%). The proportions of variance explained by sleep disturbance and negative affect for all dependent variables were greater at 3 months than 1 month. Mediation analysis was significant for negative affect for the 3-month outcomes on PROMIS pain behavior (β=.87, P<.01) and pain interference (β=.37, P<.01). There was no evidence of mediation by sleep disturbance for any outcome.

Conclusions

Negative affect and sleep disturbance are associated with worse outcomes after ESI. Further research is needed to determine if treatment of negative affect and sleep disturbance prior to or concurrently with ESI will improve outcomes.