Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD.

OBJECTIVE: This work aimed to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with posttraumatic stress disorder (PTSD). METHODS: Veterans with PTSD (N=227) participating in a multicenter trial were randomly assigned to receive a service or emotional support dog; 181 veterans received a dog and were followed up for 18 months. Primary outcomes included overall functioning (assessed with World Health Organization Disability Assessment Scale II [WHODAS 2.0]) and quality of life (Veterans RAND 12-Item Health Survey [VR-12]). Secondary outcomes included PTSD symptoms (PTSD Checklist for DSM-5), suicidal ideation, depression, sleep quality, health care costs and utilization, medication adherence, employment, and productivity. RESULTS: Participants paired with a dog had a mean±SD age of 50.6±13.6 years (range 22-79), and most were male (80%), White (66%), and non-Hispanic (91%). Adjusted linear mixed repeated-measures models indicated no difference between the two groups on WHODAS 2.0 or VR-12 scores. Participants with service dogs had a 3.7-point greater reduction in PTSD symptoms versus participants with emotional support dogs (p=0.036). No reduced health care utilization or cost was associated with receiving a service dog. Veterans with service dogs had an increase of 10 percentage points in antidepressant adherence compared with those with emotional support dogs (p<0.01). CONCLUSIONS: Both groups appeared to benefit from having a service or emotional support dog. No significant differences in improved functioning or quality of life were observed between the groups. Those in the service dog group had a greater reduction in PTSD symptoms and better antidepressant adherence, improvements that should be explored further.

Design and challenges for a randomized, multi-site clinical trial comparing the use of service dogs and emotional support dogs in Veterans with post-traumatic stress disorder (PTSD).

Posttraumatic stress disorder (PTSD) is a leading cause of impairments in quality of life and functioning among Veterans. Service dogs have been promoted as an effective adjunctive intervention for PTSD, however published research is limited and design and implementation flaws in published studies limit validated conclusions. This paper describes the rationale for the study design, a detailed methodological description, and implementation challenges of a multisite randomized clinical trial examining the impact of service dogs on the on the functioning and quality of life of Veterans with PTSD. Trial design considerations prioritized participant and intervention (dog) safety, selection of an intervention comparison group that would optimize enrollment in all treatment arms, pragmatic methods to ensure healthy well-trained dogs, and the selection of outcomes for achieving scientific and clinical validity in a Veteran PTSD population. Since there is no blueprint for conducting a randomized clinical trial examining the impact of dogs on PTSD of this size and scope, it is our primary intent that the successful completion of this trial will set a benchmark for future trial design and scientific rigor, as well as guiding researchers aiming to better understand the role that dogs can have in the management of Veterans experiencing mental health conditions such as PTSD.

Initial developmental process of a VA semistructured clinical interview for TBI identification.

Identification of a remote traumatic brain injury (TBI), particularly mild TBI, is a challenge. The acknowledged standard for determining a history of prior TBI is self-report elicited through a structured or in-depth clinical interview. In April 2007, the Veterans Health Administration (VHA) mandated that the four-section TBI Clinical Reminder screening instrument be completed on all individuals returning from deployment in the Operation Iraqi Freedom/Operation Enduring Freedom theaters of operation (VHA Directive 2007-013). If positive, a follow-up Second Level TBI Evaluation is to be completed. For validation studies of the TBI Clinical Reminder screening process and with the long-term goal of providing a structured methodology to complete the TBI history portion of the Second Level TBI Evaluation, we sought to develop a "criterion standard" semistructured clinical TBI identification interview. This tool was developed through consultation with TBI subject matter experts and built on the strengths of existing tools in the literature. This article describes the six-step developmental methodology and presents the resulting semistructured interview and accompanying manual.

Activity and participation after spinal cord injury: state-of-the-art report.

The importance of activities and community participation for persons with spinal cord injury (SCI) has been recognized for decades and yet theoretical and empirical advances have been limited. This report summarizes the recommendations for researchers on the topic of measuring activity and participation among persons with SCI formulated by the Spinal Cord Injury workgroup at the State-of-the-Art Conference on Outcome Measures in Rehabilitation held in January 2010. Activity and participation were defined as independent constructs ideally measured in reference to personal values and environmental influences. Measures of activity, participation, and factors influencing activity and participation are reviewed and critiqued. Gaps in available measures are described, measures in development are discussed, and suggestions for future research are made.

Validity of the Veterans Health Administration's traumatic brain injury screen.

OBJECTIVE: To compare the results of Veterans Affairs' (VA's) initial traumatic brain injury (TBI) Clinical Reminder Screen with the more extensive second-level Comprehensive TBI Evaluation in a national sample. DESIGN: Criterion-standard. SETTING: Veterans Health Administration system of polytrauma care. PARTICIPANTS: The data were from VA's centralized database Patient Care Services on the TBI Clinical Reminder Screen and Comprehensive TBI Evaluation results of veterans (N=48,175). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Sensitivity, specificity, positive predictive value, and negative predictive value of the TBI Clinical Reminder Screen were calculated by using the Comprehensive TBI Evaluation findings as the comparative standard for TBI confirmation. RESULTS: The TBI Clinical Reminder Screen has generally good sensitivity (.87-.90) but poor specificity (.13-.18). In addition, the TBI Clinical Reminder Screen, when compared with the Comprehensive TBI Evaluation by a clinician, has generally poor negative predictive power (.31-.49) in this sample. However, negative predictive power is good with an estimated Veterans Health Administration system-wide TBI prevalence rate of 15% (.89). Positive predictive power was acceptable (.77) in this sample. The screen performs comparably across patient demographic and symptom severity characteristics, as well as across level of polytrauma care. Systematic evaluations by clinicians primarily reveal mental health-perceived causes of ongoing symptoms. CONCLUSIONS: In summary, VA's Clinical Reminder Screen, when evaluated against the follow-up Comprehensive TBI Evaluation, has good sensitivity but poor specificity.

Medical utilization and cost outcomes for poststroke veterans who receive assistive technology devices from the Veterans Health Administration.

The study objectives were to (1) advance understanding of the relationship between provision of assistive technology devices (ATDs) and healthcare consumption and outcomes in a system that does not limit provision of ATDs to in-home use and (2) determine how the provision of ATDs relates to inpatient/outpatient utilization and costs of services for veterans 12 months poststroke when controlling for case-mix. This was a retrospective study using Department of Veterans Affairs administrative/workload databases to identify 12,046 veterans with stroke during fiscal years 2001 and 2002. Measures were functional gain, inpatient days, outpatient visits, and inpatient and outpatient costs during the first year poststroke. Motor gain for veterans receiving ATDs was higher than for veterans not receiving ATDs (20 vs 9 Functional Independence Measure points, p < 0.001). Provision of a low-end manual wheelchair was associated with increased inpatient days and costs (both p < 0.001). Provision of a power wheelchair was associated with increased inpatient (p = 0.03) and outpatient costs (p < 0.001). Provision of a scooter was associated with increased outpatient visits and outpatient costs (both p < 0.001). Scooters, walking aids, and power wheelchairs were associated with increased outpatient visits, perhaps functioning as outpatient/community enablers.

Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: A review of the literature.

The purpose of this paper was to review the literature through a structured literature review and provide a grade of recommendation for patient safety, gait energy efficiency, and cost effectiveness of the C-Leg microprocessor-controlled prosthetic knee for transfemoral amputees. Medline (Ovid) and CINAHL (EBSCO) data bases were searched to identify potentially pertinent studies within the 1995-2009 time range. Studies were screened and sorted. Pertinent studies were rated for methodologic quality and for risk of bias. Following assessment of methodologic quality and bias risk, the level of evidence and a grade of recommendation was determined for each of three categories: Safety, energy efficiency, and cost effectiveness. A total of 18 articles were determined to be pertinent: seven for safety, eight for energy efficiency, and three for cost effectiveness. Methodologic quality was low with a moderate risk of bias in the safety and energy effectiveness categories. Studies in cost effectiveness received high scores for methodologic quality. Though methodologic quality varied across the selected topics, there was sufficient evidence to suggest increased efficacy of the C-Leg in the areas of safety, energy efficiency and cost when compared with other prosthetic knees for transfemoral amputees.

Wheelchair-related falls in veterans with spinal cord injury residing in the community: a prospective cohort study.

OBJECTIVES: (1) To determine the incidence of wheelchair falls and fall-related injuries in persons with spinal cord injury (SCI) living in the community. (2) To predict wheelchair-related falls and associated injuries from specific parameters including characteristics of the wheelchair user, wheelchair type and features, health care practices, wheelchair activities, and physical environment. DESIGN: This prospective cohort study followed participants monthly over 1 year; data were collected through surveys, interviews, performance testing, observation, and medical records. SETTING: Three Veterans' Administration hospitals. PARTICIPANTS: Convenience sample of community-dwelling persons with SCI who used a wheelchair as their primary means of mobility (N=702). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Self-reports of wheelchair falls and fall-related injuries, Wheelchair User Characteristics Survey, Health Status Checklist, Health-Related Behaviors, Zuckerman Sensation Seeking Scale, Wheelchair and Equipment-Related Behaviors, Wheelchair Characteristics, Wheelchair Skills Test, and Physical Environment Assessment. RESULTS: Of the 659 subjects who completed the study, 204 participants (31%) reported 553 fall events, and 95 subjects (14%) were injured as a result of wheelchair falls. A logistic regression model for predicting wheelchair falls identified 6 significant risk factors: pain in previous 2 months, alcohol abuse, greater motor function, history of previous fall, fewer SCI years, and shorter length of wheelchair. Eighty-two percent of the variance for wheelchair fall events was explained by these 6 variables. A logistic regression model for predicting injurious falls identified 4 significant risk factors: pain in previous 2 months, greater motor function, history of previous fall, and inaccessible home entrance. These 4 factors were able to explain 81% of the variance for injurious falls. CONCLUSIONS: This is the first study to determine the incidence of wheelchair-related falls in community-dwelling people with SCI who use a wheelchair. Results indicate the incidence of falls was 31% and injurious falls was 14%. Those at greatest risk can be predicted from some readily available information regarding their clinical status, wheelchair features, and home environment.