The Use and Perceptions of the Defense and Veterans Pain Rating Scale by Nursing Personnel.

BACKGROUND: In 2010, the Office of the US Army Surgeon General recommended the Veterans Administration (VA) assess pain using the Defense and Veterans Pain Rating Scale (DVPRS). One item in the DVPRS is for measuring pain intensity. This item contains a combination of five response metrics: categories, faces, colors, numbers, and functional descriptors. A few studies have supported patients' and health care providers' preferences for the DVPRS and its psychometric properties. However, they also left uncertainties about its usability and validity. AIMS: To advance our understanding of the DVPRS, this study examined the use and perceptions of the DVPRS' pain intensity item by nursing personnel during multi-modal care. DESIGN: A cross-sectional survey design was used. SETTING: VA Community Living Center. PARTICIPANTS: Nursing personnel. METHODS: Nursing personnel answered closed- and open-ended survey questions during a single session. RESULTS: Nursing personnel reported sufficient training before implementing the measure and that patients primarily used the numeric metric. When patients used a non-numeric metric, the nursing personnel responded in variable ways. In addition, the nursing personnel interpreted the functional descriptors differently. The nursing personnel also noted the need to supplement the pain intensity item with patients' pain duration and pain location. CONCLUSIONS: Results from this study inform the nursing community about the DVPRS' pain intensity item, which combines multiple response metrics. The results support the need for nursing units to generate and standardize procedures for using the item to measure multi-site pain and for interpreting and documenting patients' non-numeric responses. The effects of such procedures on the measure's usability and psychometric properties warrants additional investigation.

The influence of breast cancer related lymphedema on women's return-to-work.

BACKGROUND: Lymphedema is one of the major treatment complications following breast cancer surgery and radiation. As the majority of women who develop breast cancer are at the age of employment, occupational functioning and employment are issues of concern. This study is novel in exploring the ways that lymphedema affects their work experience. METHODS: A multiple-case study methodology drawn from Yin's definition was employed. A total of 13 female survivors who developed breast cancer-related lymphedema participated by completing a survey and a 60-min semi-structured interview. RESULTS: Four main themes emerged: (1) breast cancer-related lymphedema affects physical and emotional functioning associated with work; (2) ongoing treatment for breast cancer-related lymphedema creates challenges for work; (3) environmental factors affect the return-to-work experience; and (4) personal factors play a key role in adjusting to return-to-work. CONCLUSION: Both breast cancer-related lymphedema and its treatment have direct and indirect effects on work, with environmental and personal factors also shaping the work-return experience. This study suggests that breast cancer survivors with lymphedema who wish to return to work face potential barriers, and that gaps remain in the availability of supports.

Is This Within Reach? Left but Not Right Brain Damage Affects Affordance Judgment Tendencies.

The ability to judge accurately whether or not an action can be accomplished successfully is critical for selecting appropriate response options that enable adaptive behaviors. Such affordance judgments are thought to rely on the perceived fit between environmental properties and knowledge of one's current physical capabilities. Little, however, is currently known about the ability of individuals to judge their own affordances following a stroke, or about the underlying neural mechanisms involved. To address these issues, we employed a signal detection approach to investigate the impact of left or right hemisphere injuries on judgments of whether a visual object was located within reach while remaining still (i.e., reachability). Regarding perceptual sensitivity and accuracy in judging reachability, there were no significant group differences between healthy controls (N = 29), right brain damaged (RBD, N = 17) and left brain damaged stroke patients (LBD, N = 17). However, while healthy controls and RBD patients demonstrated a negative response criterion and thus overestimated their reach capability, LBD patients' average response criterion converged to zero, indicating no judgment tendency. Critically, the LBD group's judgment tendency pattern is consistent with previous findings in this same sample on an affordance judgment task that required estimating whether the hand can fit through apertures (Randerath et al., 2018). Lesion analysis suggests that this loss of judgment tendency may be associated with damage to the left insula, the left parietal and middle temporal lobe. Based on these results, we propose that damage to the left ventro-dorsal stream disrupts the retrieval and processing of a stable criterion, leading to stronger reliance on intact on-line body-perceptive processes computed within the preserved bilateral dorsal network.

Does it fit? - Impaired affordance perception after stroke.

Affordance perception comprises the evaluation of whether our given bodily capabilities and properties of the environment allow particular actions. Typical impairments after left brain damage in motor cognition as well as after right brain damage in visuo-spatial abilities may affect the evaluation of whether interactions with objects are possible. Further it is unclear whether deficient motor function is accounted for when deciding upon action opportunities. For these purposes we developed a paradigm with two tasks that differ in their type of demands on affordance perception and tested it in healthy young adults (Randerath and Frey, 2016). Here, we applied one of these two tasks in stroke patients and age matched healthy participants. A sample of 34 stroke patients with either left (LBD) or right brain damage (RBD) and 29 healthy controls made decisions about whether their hands would fit through a defined horizontal aperture presented in various sizes, while they remained still. Data was analyzed using a detection theory approach and included criterion, perceptual sensitivity and diagnostic accuracy as dependent variables. In addition we applied modern voxel based lesion analyses to explore neural correlates. Compared to controls, both patient groups demonstrated lower perceptual sensitivity. As predicted, increased motor cognitive deficiencies after left brain damage and visuo-spatial deficits after right brain damage were associated with worse performance. Preliminary lesion analyses demonstrated that next to lesions in ventro-dorsal regions, damage in the cortex-claustrum-cingulate pathway may affect perceptual sensitivity. Results were similar for left and right brain damage suggesting a bilateral network. Accordingly, we propose that perceptual sensitivity for affordance based judgments is a capability depending on motor-cognitive and visuo-spatial processing, which frequently is deficient after left or right brain damage, respectively. Further research on diagnostics and training in affordance perception after brain damage is needed.

Return to work among breast cancer survivors: A literature review.

PURPOSE: Breast cancer survivors in their employment years are likely to try to go back to work after the primary treatment. Because the literature on return to work among breast cancer survivors is limited, we have undertaken a review of the literature to summarize what is known, including identifying important contributing variables and outcomes. This knowledge may be used to develop hypotheses and potential interventions to support breast cancer survivors who wish to return to work. METHOD: We searched the following databases: CINAHL, MEDLINE, SCOUP, and PUBMED, within a 10-year timeframe (2004 to 2014). RESULTS: The majority of reviewed articles (N = 25) focused on three outcomes: return-to-work period, work ability, and work performance. The most frequently studied independent variables were collapsed into the following groups: health and well-being, symptoms and functioning, work demands and work environment, individual characteristics, and societal and cultural factors. Gaps in the literature include evidence of effective interventions to support return to work among breast cancer survivors and research to better understand the roles of government and business-related policy. CONCLUSION: All the studies reported a reduced work engagement and work ability. Employment status and work performance is associated with a combination of individual factors, work environment, culture, and resources. IMPLICATIONS: Significant gaps are apparent in the literature addressing breast cancer survivorship and return to work. This is a complex problem and it will likely require interdisciplinary research teams to develop effective and feasible interventions for this population.

Rehabilitation of poststroke cognition.

Given the increasing rates of stroke and our aging population, it is critical that we continue to foster innovation in stroke rehabilitation. Although there is evidence supporting cognitive rehabilitation in stroke, the set of cognitive domains effectively addressed to date represents only a small subset of the problems experienced by stroke survivors. Further, a gap remains between investigational treatments and our evolving theories of brain function. These limitations present opportunities for improving the functional impact of stroke rehabilitation. The authors use a case example to encourage the reader to consider the evidence base for cognitive rehabilitation in stroke, focusing on four domains critical to daily life function: (1) speech and language, (2) functional memory, (3) executive function and skilled learned purposive movements, and (4) spatial-motor systems. Ultimately, they attempt to draw neuroscience and practice closer together by using translational reasoning to suggest possible new avenues for treating these disorders.

Successful weight loss: how information technology is used to lose.

BACKGROUND: Commercial producers have outpaced traditional academic healthcare in terms of novel repackaging of traditional approaches to weight control for online delivery. Little is known, however, about consumers' experiences with such products and services. We explored ways that people use information technology (IT) to facilitate health-related behavioral change. MATERIALS AND METHODS: Qualitative methods and grounded theory methodology were used to analyze transcripts of audiotaped material from three focus groups, each with 12 participants. Participants were recruited from an ongoing, community-wide weight-loss event, who reported regular or frequent use of IT. RESULTS: Participants frequently used IT applications for completing functional tasks associated with weight loss. In contrast, most participants preferred in-person social support. IT applications facilitated integration of behavior change tasks into everyday life. Despite easy access to a range of social networking Web sites and tools, however, having access to in-person social support was targeted as critical to successful weight loss and well-being. To this end, the role of work peers and work environments was emphasized by these participants. CONCLUSIONS: In terms of patient care, successful health portals may benefit from either developing or integrating existing IT applications that save time and/or provide users with visual feedback on progress toward goals. IT-delivered resources would likely optimize community-based behavioral health interventions that target naturally occurring social groups.

Upper extremity lymphedema: presence and effect on functioning five years after breast cancer treatment.

PURPOSE/OBJECTIVE: Our goal was to explore the effects of lymphedema on long-term adjustment among breast cancer survivors, in terms of functioning in important life environments. RESEARCH METHOD/DESIGN: Limb volume measurements and psychosocial survey data were collected from women shortly after undergoing surgical intervention for breast cancer and annually thereafter. A subset of these women were selected for the current study because they had preoperative limb volume measurement data, which is best suited to determine presence and severity of lymphedema. Our final sample of 61 women had both the arm measurements (preoperative and 5-year) and survey data (baseline and 5-year) needed for this study, which comprises a secondary cross-sectional analysis of longitudinal data. A correlational approach was used to explore associations among lymphedema (presence, severity, and whether the participant met the criteria for lymphedema at any assessment point since their treatment for breast cancer) and outcome variables (physical functioning, vocational functioning, social functioning, domestic functioning, and sexual functioning). RESULTS: Each of the three measures of lymphedema was significantly correlated with domestic functioning, but not with functioning in other common environments. CONCLUSIONS/IMPLICATIONS: Long-term breast cancer survivors are at risk for developing secondary conditions, such as lymphedema, to which they must learn to adjust and adapt. Lymphedema may increase risk for compromised functioning in everyday environments, a problem which lies at the heart of rehabilitation. Breast cancer survivorship, therefore, fits well within the scope of a rehabilitation framework.

Communication during patient-provider encounters regarding diabetes self-management.

BACKGROUND AND OBJECTIVES: Diabetes is a common chronic illness with potentially severe complications. The risk of complications is reduced through controlling blood sugar, lipids, and blood pressure. While medical intervention is important, substantial self-management on the part of patients is required to achieve good control. Patients often find self-management difficult, particularly diet and exercise modification. Clinicians face barriers as well, including lack of time, poor reimbursement, and difficulty changing their clinical practice patterns. We hypothesized that a strong focus on readily measured disease indicators competes with patients' agendas relating to symptoms and their day-to-day social context. METHODS: We recorded clinical encounters to study communication about self-management in context. Recordings were transcribed verbatim and analyzed, primarily using a grounded theory approach. RESULTS: We found that clinicians often focused their communication on quantitative measures such as blood pressure and glycosylated hemoglobin but that patients found it difficult to relate these measures to how they were feeling physically. Patients' social contexts influenced their self-management activities, in particular heavy caregiving responsibilities and work schedules. CONCLUSIONS: Supporting self-management of patients with diabetes requires providers to link clinical measurements to patients' symptoms and likely outcomes. It is difficult for providers to know what support or assistance their patients need without knowledge of patients' social contexts.

Patient-provider communication about diabetes self-care activities.

BACKGROUND AND OBJECTIVES: Controlling diabetes requires sustained self-management on the part of patients. Health care providers can support patients' self-care efforts through communication and problem solving. We conducted this study to determine the frequency with which self-care activities were discussed during office visits for follow-up care of diabetes and how much time was spent on these discussions. METHODS: Audio recordings of 28 patient encounters in five primary care clinics were analyzed. We determined the frequency of self-care discussions and the amount of time devoted to these discussions. RESULTS: Self-care was discussed in all 28 encounters. Median encounter times for each clinic ranged from 19.8 to 37.6 minutes, with self-care discussions taking from 0.1 to 17.2 minutes. Median discussion time devoted to all self-care activities was 5.2 minutes, representing 23.5% of a visit of median length. Blood sugar testing was discussed longer than the other activities. The least time was devoted to eye and foot examinations. Discussions were usually initiated by providers and did not differ in length according to who initiated the discussion. CONCLUSIONS: Patients with diabetes regularly discussed self-care activities during follow-up visits at family medicine clinics. Providers varied in their capacity to incorporate self-care planning into routine medical care for patients with diabetes. Interventions are needed that help improve goal-setting and documentation. Documentation of self-care discussions will be important for meeting Meaningful Use criteria.

RAHelp: an online intervention for individuals with rheumatoid arthritis.

OBJECTIVE: To test an intervention for improving self-management in rheumatoid arthritis (RA) using an online, cognitive-behavioral, self-management group program (RAHelp), with weekly telephone support. METHODS: A 2-group, randomized study design was used to compare an intervention for RA versus a waiting-list control condition. The intervention used a secure web site (RAHelp.org) to provide a 10-week program with weekly educational modules for improving self-efficacy in self-management of RA, plus tools for group interaction. Weekly telephone contacts were made to encourage use of program tools and apply newly learned skills. A nationwide convenience sample of 106 adult participants (mean age 50 years, 93% women) was recruited primarily through online advertisements. Main outcome measures included the Arthritis Impact Measurement Scales 2 (affective, physical, role, social, and pain/symptom components), Arthritis Self-Efficacy Scale (ASES), Center for Epidemiologic Studies Depression Scale, Quality of Life Scale (QLS), Rapid Assessment of Disease Activity in Rheumatology, Social Provisions Scale, and University of California, Los Angeles Loneliness Scale 3. RESULTS: Group differences with large and moderate effect sizes (ES) were found immediately postintervention for self-efficacy (ASES; ES 0.92, P = 0.00001) and quality of life (QLS; ES 0.66, P = 0.003), respectively. At 9 months postintervention, differences in self-efficacy (ASES; ES 0.92, P = 0.00001) and quality of life (QLS; ES 0.71, P = 0.004) remained robust. CONCLUSION: RAHelp appears to have beneficial effects in terms of self-efficacy and quality of life among individuals with RA who are willing to use an online service format.

Disability on campus: a perspective from faculty and staff.

OBJECTIVE: To identify employee perceptions regarding disability-related workplace issues in Institutions of Higher Education (IHE). PARTICIPANTS: Faculty and staff (N=1,144) at a large, Midwestern university. METHODS: A voluntary on-line survey of disability-related employment issues was developed by the university's Chancellor's Committee of Persons with Disabilities. Item responses were analyzed using descriptive and Pearson chi-square statistical methods. RESULTS: Fifteen percent of faculty and staff respondents were found to have disabilities, with 26% reporting experience of job discrimination, and 20% reporting harassment because of their disability. Results indicated significant differences on gender, employment standing (i.e., faculty or staff) and disability status (i.e., with or without a disability), in regard to perceptions of disability acceptance, campus accessibility, disability awareness, ADA policy, and knowledge of work accommodation procedures. CONCLUSIONS: Recommendations for IHEs are provided to promote a welcoming and inclusive campus that ultimately supports work success for persons with a disability.

Online self-management in rheumatoid arthritis: a patient-centered model application.

OBJECTIVE: The aim of this study was to describe the online transformation of an empirically validated, clinic-based, self-management (SM) program for rheumatoid arthritis. MATERIALS AND METHODS: A cognitive-behavioral framework served as the theoretical basis for the intervention. As with the clinic-based approach, the psychoeducational program included educational modules, weekly homework assignments, and self-evaluation. The dynamic online environment included secure communication tools to support a virtual community for the participants to garner peer support. In addition to peer support, weekly follow-up support was provided by a trained clinician via telephone. We describe the process and structure of the online self-management (OSM) intervention. Administrative issues including clinical monitoring and management, data collection, and security safeguards are considered. Utilization and management data are provided and explored for 33 initial subjects. RESULTS: Individuals who volunteer to participate in an online modality are eager to receive this home-based programming. They readily engaged with all aspects of the OSM program and experienced few difficulties navigating the environment. CONCLUSION: An OSM site provides a convenient, effective, and securely maintained health service, once restricted to clinic settings. The OSM application can be used to extend the benefits of SM programs to broad target audiences and serves as a model for the emerging generation of Internet-based clinical management/delivery systems.

Motivation and diabetes self-management.

OBJECTIVE: To examine the relationship between autonomous motivation and diabetes self-care activities among individuals with diabetes. METHODS: Seventy-seven individuals recruited from outpatient clinic registries (64% female, 77% Caucasian, mean age 63 years) completed measures of diabetes-related self-care (Summary of Diabetes Self-care Activities), motivation (Treatment Self-regulation Questionnaire), health literacy (Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign), health (SF-36v2), social support (Social Support Survey) and self-efficacy (Perceived Competence Scale). RESULTS: Autonomous motivation was the only variable significantly associated with maintaining diet (p<0.0001) and blood glucose testing (p<0.04) in regression analyses. No significant associations were identified for exercise. The variable of age approached significance (p = 0.06), with older individuals being less likely to have exercised in the past week. DISCUSSION: Individuals in this study had difficulty in maintaining self-care demands, especially exercise. Meeting recommended levels of self-care activity was challenging, even for patients with adequate levels of health literacy. Individuals with higher levels of autonomous motivation reported higher frequencies for maintaining diet and testing blood glucose, however, which supports the utility of Self-Determination Theory in promoting diabetes self-care.

Nurse partners in chronic illness care: patients' perceptions and their implications for nursing leadership.

PURPOSE: To examine how patients with multiple chronic conditions perceive the role of nurses who function in a care management role in a primary healthcare setting. PARTICIPANTS: Thirteen patients between the ages of 56 and 88 years were recruited from an outpatient family practice clinic. All participants had type 2 diabetes, plus at least 1 chronic comorbid condition. METHOD: Data were collected using a semistructured interview protocol and analyzed using an iterative process. Interviews were coded independently by the core team and emerging themes were identified through weekly discussion. Discrepancies in coding and interpretation were resolved by reviewing transcripts and field notes as a group until consensus was reached. The core team met twice with advisory members to review conceptual constructs. CONCLUSIONS: Three themes emerged: (1) an overwhelming positive regard for the nurse partner, both as a person and a professional; (2) appreciation for the availability of the nurse partner; and (3) a perceived partnership with healthcare providers. Results provide evidence that the role is appreciated and that nurses provide care that is commensurate with patients' expectations and desires for healthcare. Future research must demonstrate the efficiency and sustainability of care coordination services for patients with chronic illness.

Financial and vocational outcomes 2 years after traumatic brain injury.

PURPOSE: To determine outcomes for persons with traumatic brain injury (TBI) in terms of employment status, income and public assistance received at 2 years after injury. METHOD: This study was part of a non-experimental, longitudinal survey. Participants included 49 persons with new TBI from one US national Traumatic Brain Injury Model Systems centre. Main outcome measures included employment status, earned monthly income and monthly income from public sources, at the time of injury and at 2-years follow-up. RESULTS: At 2-year follow-up, individuals with TBI reported higher levels of employment and earned income than was previously reported for 1-year post-injury, but continued to experience declines relative to pre-injury baseline. Frequency and amount of major public agency payments continued to be increased relative to baseline. CONCLUSIONS: The costs associated with brain injury remain high for individuals, families and society, as those with TBI move into the more chronic phase of recovery.

Social interactions in an online self-management program for rheumatoid arthritis.

OBJECTIVE: To evaluate social interactions among individuals with rheumatoid arthritis (RA), participating in an empirically based, cognitive-behavioural, self-management (SM), and peer-support program, delivered in an online format. METHODS: Thirty individuals with RA were recruited online. Subjects were a subset of participants in the treatment arm of a waiting-list controlled study testing the effectiveness of a 10-week, online, SM education and peer support program. Primary outcomes were process variables describing social activity in the online environment during active treatment. Qualitative review of discussion board posts was undertaken to gain insight into participants' perceptions of social interactions. RESULTS: Participants spent a large proportion of logged-in time accessing educational materials and community-level activity was vibrant, with members utilizing the discussion board and e-mail. The Chat feature was less well-used. Discussion board posts regarding RAHelp were very positive, especially in regard to perceived supportiveness and bonding among participants, and a sense of feeling uniquely understood by others who have RA. Concern arose in response to periods in which the discussion board was 'too quiet'. DISCUSSION: Our work complements the emerging literature supporting acceptance and utility of Internet-based programming as a venue for SM education and social interaction among individuals with chronic illness.

Relationships among religiousness, spirituality, and health for individuals with stroke.

The current study evaluated the relationships among spiritual beliefs, religious practices, physical health, and mental health for individuals with stroke. A cross-sectional analysis of 63 individuals evaluated in outpatient settings, including 32 individuals with stroke and 31 healthy controls was conducted through administration of the Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) and the Medical Outcomes Scale-Short Form 36 (SF-36). For individuals with stroke, the SF-36 General Mental Health scale was significantly correlated with only the BMMRS Religious and Spiritual Coping scale (r = .43; p < .05). No other BMMRS factors were significantly correlated with SF-36 mental or physical health scales. Non-significant trends indicated spiritual factors were primarily related to mental versus physical health. This study suggests spiritual belief that a higher power will assist in coping with illness/disability is associated with better mental health following stroke, but neither religious nor spiritual factors are associated with physical health outcomes. The results are consistent with research that suggests that spiritual beliefs may protect individuals with stroke from experiencing emotional distress.

A review of employability and worksite interventions for persons with rheumatoid arthritis and osteoarthritis.

Arthritis has a significant effect on the US workforce. Significant economic effects and racial disparities have been found in treatment and health outcomes for persons with arthritis. This literature review focuses on the most commonly studied forms of arthritis, osteoarthritis (OA) and rheumatoid arthritis (RA), summarizing literature on employability trends, risk factors, and worksite health interventions for these conditions. Recommendations and future implications for research are given in relation to goals from Healthy People 2010. A brief description is provided of a worksite comparative study at the Missouri Arthritis Rehabilitation Research and Training Center (MARRTC), seeking to improve long-term employability and functional outcomes for persons with arthritis.

Outcomes in TBI with violent versus nonviolent etiology in a predominantly rural setting.

OBJECTIVE: To evaluate differences in outcome in persons with violent versus nonviolent traumatic brain injury (TBI) etiology. DESIGN: Two-group (violent vs nonviolent) 1-year follow-up study. SETTING: Midwestern medical center TBI Model System serving a predominantly rural catchment area. PARTICIPANTS: Forty-five (n = 19 violent TBI etiology; n = 26 nonviolent TBI etiology) inpatients with primary diagnosis of TBI followed up as outpatients 1 year after injury. MAIN OUTCOME MEASURES: Substance use, income source, employment status, Wechsler Adult Intelligence Scale--Revised (abbreviated version), Logical Memory I and II from the Wechsler Memory Scale--Revised, Wide Range Achievement Test--Third Edition Reading subtest, Trail-Making Tests A and B, Rey Auditory Verbal Learning Test, Community Integration Questionnaire, Neurobehavioral Functioning Inventory. RESULTS: Members of the violent group were more likely to be men, of a racial minority, unemployed, and have low income. Substance abuse was common among both groups prior to injury, with significant declines at 1 year. Follow-up also revealed significant group differences in verbal intelligence, social integration, productivity, and source of income, but nonsignificant difference in employment. In all comparisons, more favorable outcomes were found for the nonviolent group. CONCLUSIONS: Persons with violent injury etiology have poorer premorbid functioning and are likely to have less favorable outcomes than the general population with TBI. Therefore, persons with violent TBI etiology may require more intensive aftercare programming to promote improved rehabilitation outcomes.