Relative Meaningfulness and Impacts of Symptoms in People with Early-Stage Parkinson's Disease.

BACKGROUND: Patient perspectives on meaningful symptoms and impacts in early Parkinson's disease (PD) are lacking and are urgently needed to clarify priority areas for monitoring, management, and new therapies. OBJECTIVE: To examine experiences of people with early-stage PD, systematically describe meaningful symptoms and impacts, and determine which are most bothersome or important. METHODS: Forty adults with early PD who participated in a study evaluating smartwatch and smartphone digital measures (WATCH-PD study) completed online interviews with symptom mapping to hierarchically delineate symptoms and impacts of disease from "Most bothersome" to "Not present," and to identify which of these were viewed as most important and why. Individual symptom maps were coded for types, frequencies, and bothersomeness of symptoms and their impacts, with thematic analysis of narratives to explore perceptions. RESULTS: The three most bothersome and important symptoms were tremor, fine motor difficulties, and slow movements. Symptoms had the greatest impact on sleep, job functioning, exercise, communication, relationships, and self-concept- commonly expressed as a sense of being limited by PD. Thematically, most bothersome symptoms were those that were personally limiting with broadest negative impact on well-being and activities. However, symptoms could be important to patients even when not present or limiting (e.g., speech, cognition). CONCLUSION: Meaningful symptoms of early PD can include symptoms that are present or anticipated future symptoms that are important to the individual. Systematic assessment of meaningful symptoms should aim to assess the extent to which symptoms are personally important, present, bothersome, and limiting.

Mapping Relevance of Digital Measures to Meaningful Symptoms and Impacts in Early Parkinson's Disease.

BACKGROUND: Adoption of new digital measures for clinical trials and practice has been hindered by lack of actionable qualitative data demonstrating relevance of these metrics to people with Parkinson's disease. OBJECTIVE: This study evaluated of relevance of WATCH-PD digital measures to monitoring meaningful symptoms and impacts of early Parkinson's disease from the patient perspective. METHODS: Participants with early Parkinson's disease (N = 40) completed surveys and 1:1 online-interviews. Interviews combined: 1) symptom mapping to delineate meaningful symptoms/impacts of disease, 2) cognitive interviewing to assess content validity of digital measures, and 3) mapping of digital measures back to personal symptoms to assess relevance from the patient perspective. Content analysis and descriptive techniques were used to analyze data. RESULTS: Participants perceived mapping as deeply engaging, with 39/40 reporting improved ability to communicate important symptoms and relevance of measures. Most measures (9/10) were rated relevant by both cognitive interviewing (70-92.5%) and mapping (80-100%). Two measures related to actively bothersome symptoms for more than 80% of participants (Tremor, Shape rotation). Tasks were generally deemed relevant if they met three participant context criteria: 1) understanding what the task measured, 2) believing it targeted an important symptom of PD (past, present, or future), and 3) believing the task was a good test of that important symptom. Participants did not require that a task relate to active symptoms or "real" life to be relevant. CONCLUSION: Digital measures of tremor and hand dexterity were rated most relevant in early PD. Use of mapping enabled precise quantification of qualitative data for more rigorous evaluation of new measures.

A multilevel perspective on goals, barriers, and facilitators of school-based asthma management.

BACKGROUND: School based asthma care is being increasingly used to combat uncontrolled pediatric asthma. OBJECTIVE: The purpose of these secondary analyses was to explore multi-level perspectives regarding school-based asthma medical management for inner city, school-aged children with poor asthma control. METHODS: Sixty-six participants from two large U.S. urban school districts and key stakeholders participated in 1:1 interviews and focus groups. Participants were selected from across the asthma care community (children/caregivers, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative and descriptive techniques were used to analyze data. RESULTS: Goals: Children/caregivers prioritized living a normal active life with few asthma worries. Other stakeholders prioritized reducing student's asthma related emergency room visits and lost learning time. Facilitators: Continuity of care, strong relationships between care community members, and incentivizers were commonly suggested facilitators. School-based asthma management was viewed as a strong facilitator, particularly in the presence of a full-time school nurse. Barriers: Four themes were identified. (1) Greater systems and policy support for asthma management is needed in general, and at school in particular. (2) Overburdened families and systems often operate in crisis-mode, and asthma management is often not a priority until crisis is reached. (3) Discordance and distrust between members of the asthma care community can hinder shared asthma management. (4) Better communication is needed at all levels to improve care. CONCLUSION: Moving away from a crisis-based approach to asthma management for high-risk children will require increased systemic support for proactive asthma care and optimized communication within the asthma care community.Supplemental data for this article is available online at https://dx.doi.org/10.1080/02770903.2021.2018704.

Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS).

BACKGROUND: The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes. METHODS: TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical record-based clinical decision support software. Adults aged 18-44 (N = 33) and primary care providers (N = 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV1 were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes. RESULTS: At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d = 1.955, d = 1.579). FEV%pred increased 4.2% (d = 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI = 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI = 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective self-management, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma. DISCUSSION: Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

Summary of the 2020 focused updates to U.S. asthma management guidelines: What has changed and what hasn't?

ABSTRACT: Despite the availability of effective medications, the majority of pediatric and adult patients with persistent asthma have uncontrolled symptoms. This has been attributed to patient nonadherence and poor self-management, but clinicians also contribute through inaccurate assessment of asthma and lack of familiarity with best practice guidelines for medication management. Thus, improving patient outcomes will require improving clinical management by health care providers, including utilization of evidence-based practice guidelines. In this report, we briefly summarize key points of the national guidelines for asthma management and delineate important changes enacted by 2020 Expert Panel Report-4 updates. These include revised recommendations on the use of fractional exhaled nitric oxide testing, indoor allergen mitigation, bronchial thermoplasty, adjunctive immunotherapy, and important modifications to medication management that are likely to have widespread impact on prescribing throughout the United States. In particular, for all patients aged five years and older taking stepwise therapy levels 3-4, it is now recommended to use Single Maintenance and Reliever Therapy, whereas the use of intermittent inhaled corticosteroids (ICSs) administered at the same time as short-acting beta agonist is recommended for step 2 to reduce symptom burden, improve control, and minimize total ICS dose.

Understanding the genetics of chronic obstructive pulmonary disease, α1-antitrypsin deficiency, and implications for clinical practice.

ABSTRACT: Cigarette smoking and poor air quality are the greatest risk factors for developing chronic obstructive pulmonary disease (COPD), but growing evidence indicates that genetic factors also affect predisposition to and clinical expression of disease. With the exception of α1-antitrypsin deficiency (AATD), a rare autosomal recessive disorder that is present in 1-3% of individuals with COPD, no single gene is associated with the development of obstructive lung disease. Instead, a complex interplay of genetic, epigenetic, and environmental factors is the basis for persistent inflammatory responses, accelerated cell aging, cell death, and fibrosis, leading to the clinical symptoms of COPD and different phenotypic presentations. In this brief review, we discuss current understanding of the genetics of COPD, pathogenetics of AATD, epigenetic influences on the development of obstructive lung disease, and how classifying COPD by phenotype can influence clinical treatment and patient outcomes.

Development and preliminary results of an Electronic Medical Record (EMR)-integrated smartphone telemedicine program to deliver asthma care remotely.

INTRODUCTION: Technology-based interventions that can function within real-world practice and improve outcomes without increasing provider burden are needed, yet few successfully cross the research-to-practice divide. This paper describes the process of developing a clinically integrated smartphone-telemedicine program for adults with asthma and results from proof-of-concept testing. METHODS: We used a contextually grounded intervention development approach and May's implementation theory to design the intervention, with emphasis on systems capabilities and stakeholder needs. The intervention incorporated symptom monitoring by smartphone, smartphone telemedicine visits and self-management training with a nurse, and clinical decision-support software, which provided automated calculations of asthma severity, control and step-wise therapy. Seven adults (aged 18-40 y) engaged in a 3-month beta-test. Asthma outcomes (control, quality of life, FEV1) and healthcare utilisation patterns were measured at baseline and end-of-study. RESULTS: Each participant averaged four telemedicine visits (94% patient satisfaction). All participants had uncontrolled asthma at baseline; end-of-study 5/7 classified as well-controlled. Mean asthma control improved 1.55 points (CI = 0.59-2.51); quality of life improved 1.91 points (CI = 0.50-3.31), FEV1 percent predicted increased 14.86% (CI = -3.09-32.80): effect sizes of d = 1.16, 1.09, and 0.96, respectively. Preventive healthcare utilisation increased significantly (1.86 visits/year vs. 0.28/year prior, CI 0.67-2.47) as did prescriptions for controller medications (9.29 prescriptions/year vs. 1.57 prescriptions/year, CI 4.85-10.58). DISCUSSION: Smartphone telemedicine may be an effective means to improve outcomes and deliver asthma care remotely. However, careful attention to systems capabilities and stakeholder acceptability is needed to ensure successful integration with practice.Clinical Trials registration #: NCT03648203.

Health-related internet use among adolescents with uncontrolled persistent asthma.

OBJECTIVES: To describe internet use for health information among adolescents with uncontrolled persistent asthma, and to examine whether health-related internet use is associated with responsibility for home asthma management. METHODS: We analyzed baseline data from the School-Based Asthma Care for Teens (SB-ACT) Trial, which included adolescents (12-16 years) in an urban school district who had uncontrolled persistent asthma per caregiver report. We asked adolescents whether they had ever used the Internet to look for health or medical information (Y/N). Teens then described family responsibility for 9 asthma management tasks (e.g. full caregiver responsibility, shared responsibility, or full teen responsibility). We examined responsibility sum scores in addition to responsibility for individual management tasks. We used bivariate and multivariate analyses to compare health-related internet use with participant characteristics, teen-reported asthma symptoms, and management responsibility. RESULTS: We examined data for 425 adolescents (mean age 13.4 years). Almost half (45%) reported seeking health information on the Internet. In adjusted analyses, health-related internet use was strongly associated with teen responsibility (sum score and tasks relating to carrying and using medications); internet use was also more likely among teens who were older, female, or reported uncontrolled disease. CONCLUSIONS: Adolescents with persistent asthma who share responsibility for home management or report uncontrolled disease are more likely to seek health information online. Future interventions to support teens who co-manage asthma should work to engage patients in both clinical and digital spaces, and ensure that all patients can access accurate, patient-centered asthma information when needed.

A mixed-methods analysis of younger adults' perceptions of asthma, self-management, and preventive care: "This isn't helping me none".

BACKGROUND: Young adults (ages 18-44) have increased emergency department use for asthma and poor adherence to medications. The objective of this mixed-methods study was to understand experiences with and approaches to managing asthma, of which little is known in this age group. METHODS: Surveys (Asthma Control Questionnaire, Asthma Quality of Life Questionnaire) and 1:1 semi-structured interviews were used to explore experiences with asthma, symptoms, self-management behaviours, and relationship to asthma control and quality of life. Qualitative data were analysed using content analysis techniques. Descriptive statistics and bivariate correlations were used to examine distributive characteristics and associations between variables. RESULTS: Forty urban adults participated (mean age 32.7 ± 6.2, 1σ). Coughing was reported nearly 46% more often than wheezing, with 42.5% (17/40) coughing until the point of vomiting most days. Most participants delayed using medication for symptoms due to misperceptions about inhalers. Higher symptom frequency and worse asthma control were associated with greater use of non-pharmacologic symptom management strategies (r = 0.645, P < .001; r = 0.360, P = .022, respectively). Five themes were identified regarding young adults experiences with asthma: (1) having asthma means being limited and missing out on life; (2) health care for asthma is burdensome, and other things are more important; (3) there is not enough personal benefit in medical interactions to make preventive care worthwhile; (4) there are insufficient support and education about asthma for adults; and (5) people normalize chronic symptoms over time and find ways of coping that fit with their lifestyle. CONCLUSIONS AND CLINICAL RELEVANCE: Young adults may tolerate symptoms without using quick-relief medication or seeking preventive care. Increasing engagement with preventive services will require decreasing perceived burdens and increasing the personal benefits of care. Evaluating for non-pharmacologic approaches to managing symptoms and asthma-related coughing may identify uncontrolled asthma. Enhanced training for clinicians in patient-centric asthma care may be needed.

Understanding the genetics of asthma and implications for clinical practice.

Asthma is one of the most common heritable diseases globally, with variable clinical expression and response to treatment that is attributed to underlying genetic differences. Hundreds of loci on multiple chromosomes are associated with asthma. Although routine genetic screening is not recommended, testing for medication responsiveness might soon play a role in clinical management. Pharmacogenetic research remains early stage but has demonstrated potential for both clinical and cost effectiveness. Furthermore, recognition of clinically apparent asthma phenotypes, the result of genetic and environmental interactions, can help to inform treatment decisions. Phenotypes are divided into two broad categories of atopic and nonatopic disease, with further subdivisions that are associated with clinical presentation patterns and responsiveness to treatment. In general, earlier onset and allergic disease will respond well to traditional therapy with inhaled corticosteroids (ICSs) and leukotrienes because these medications target inflammatory pathways for allergic disease. However, patients with late-onset, symptom predominant (lacking inflammation), and obese asthma might be resistant to standard therapy and may require treatment modification. These patients are at risk for overuse of ICSs with poor response and may benefit more by use of long-acting beta agonists, long-acting muscarinic agonists, weight reduction, and exercise.

Mixed-methods content and sentiment analysis of adolescents' voice diaries describing daily experiences with asthma and self-management decision-making.

BACKGROUND: Accurate symptom assessment remains challenging in teen populations. Little is known of usual symptom/response patterns, and self-reported paper diaries have traditionally low compliance rates. Therefore, we used concurrent digital voice diaries to capture daily asthma experiences. OBJECTIVE: (a) To qualitatively explore usual symptom patterns and self-management responses and (b) to quantitatively explore relationships between symptom severity and sentiment scores (a marker of emotional response to events). METHODS: Fourteen minority and nonminority teenagers (age 13-17) with controlled (50%) and uncontrolled asthma used digital recorders to report about their asthma once daily over 14 days. Dairy entries were coded for symptom frequency, severity, type, and self-management responses, while sentiment analysis was used to evaluate the emotional valence of diary entries and to explore whether increased symptom levels correlated with greater negative sentiment. RESULTS: Symptom frequency and severity recorded in voice diaries were much higher than teens indicated at baseline and were discordant with clinical assessments of asthma control. Of 175 entries, teens had symptoms 69.1% of days (121/175) and severe symptoms on one-third of these. Atypical symptoms (coughing, throat clearing) were reported twice as often as traditional symptoms (wheezing, chest tightness) and often not recognized as asthma, but rather attributed to being "sick" (25.6% of symptom days). Teens frequently minimized symptoms, used rescue and controller medication inconsistently, and resorted to alternative strategies to manage symptoms. Sentiment was not significantly correlated with assessed control (ß = 0.14, P = 0.28), but for teens reporting severe symptoms, sentiment scores decreased by 0.31 relative to teens without symptoms (P = 0.006). CONCLUSIONS AND CLINICAL RELEVANCE: Teens may minimize symptoms and have greater symptom frequency and severity than is recognized by themselves or providers. Screening for specific symptoms including coughing, throat clearing, and respiratory illness may be needed to identify those experiencing burden from asthma.

Beyond concept analysis: Uses of mind mapping software for visual representation, management, and analysis of diverse digital data.

Mind mapping is a visual-spatial method of representing information using nodes (information segments) to show ideas and connecting lines to define relationships between content. As a critical thinking tool, it is applicable to a range of research activities, including information management, project development, and data analysis. The purposes of this manuscript are to describe the use of mapping for qualitative data analysis, provide step-by-step instructions of how to construct mind maps, and present examples specific to qualitative data analysis. An example from a recent study of patient and provider perceptions of virtual visits demonstrates the use of Xmind in conjunction with Atlas.ti for qualitative content analysis of open-ended survey data. While coding in Atlas.ti, we used Xmind to develop dynamic memos, code networks, and themes. The memo map served to identify common coding patterns and informed subsequent coding stages. After coding in Atlas.ti, the entire code list was imported into a new map in Xmind and iteratively organized to identify conceptual groupings, similarities/differences, and key ideas. Themes were identified through pattern coding and refining code networks within the Xmind map. Map iterations formed part of the analytic trail and facilitated peer-to-peer discussions. The final map served as the model for publication. The use of mind mapping enhanced the rigor, credibility, and transparency of analyses and facilitated peer-to-peer communication. This technique can be used to manage diverse content (documents, audio/video file, image, web links, and personal notes) and thus has great potential to contribute to a variety of data management tasks.

Patient and Physician Perceptions of Virtual Visits for Parkinson's Disease: A Qualitative Study.

Background and Introduction: Delivering care through telemedicine directly into the patient's home is increasingly feasible, valuable, and beneficial. However, qualitative data on how patients' and physicians' perceive these virtual house calls are lacking. We conducted a qualitative analysis of perceptions of these visits for Parkinson's disease to (1) determine how patients and physicians perceive virtual visits and (2) identify components contributing to positive and negative perceptions. MATERIALS AND METHODS: Qualitative survey data were collected from patients and physicians during a 12-month randomized controlled trial of virtual house calls for Parkinson's disease. Data from 149 cases were analyzed using case-based qualitative content analysis and quantitative sentiment analysis techniques. RESULTS: Positive and negative perceptions of virtual visits were driven by three themes: (1) personal benefits of the virtual visit, (2) perceived quality of care, and (3) perceived quality of interpersonal engagement. In general, participants who identified greater personal benefit, high quality of care, and good interpersonal engagement perceived visits positively. Technical problems with the software were commonly mentioned. The sentiment analysis for patients was strongly favorable (+2.5) and moderately favorable for physicians (+0.8). Physician scores were lowest (-0.3) for the ability to perform a detailed motor examination remotely. DISCUSSION: Patients and providers generally view telemedicine favorably, but individual experiences are dependent on technical issues. CONCLUSIONS: Satisfaction with and effectiveness of remote care will likely increase as common technical problems are resolved.

Changes in asthma self-management knowledge in inner city adolescents following developmentally sensitive self-management training.

OBJECTIVE: To evaluate efficacy of a developmentally sensitive curriculum for improving asthma self-management knowledge, attitude, and self-efficacy in adolescents. METHODS: Fourty-two inner-city adolescents (ages 16-20) participated in a 12hour asthma self-management training program. Self-management knowledge, attitude toward asthma, and asthma-related self-efficacy were measured using short-answer tests before and after training. T-Tests were used to evaluate impact and effect sizes were calculated. RESULTS: Mean pretest knowledge was 21.37/46 points; mean posttest was 36.33/46 points. Change from pre- to posttest was highly significant (t=10.34; p<0.0001), with a large effect size (d=1.68). Females improved more than males (18.66±8.58 vs. 12.29±8.13, p=0.039). Greatest effects were seen in awareness of long-term consequences of uncontrolled asthma (d=2.04), ability to recognize symptoms of life-threatening asthma (d=1.61), correctly monitor symptoms (d=1.49), and tell if asthma was uncontrolled (d=1.39). Asthma self-efficacy also improved significantly (p=0.017), particularly confidence in ability to correctly manage asthma, however improvements in attitude did not achieve statistical significance. CONCLUSION: Developmentally appropriate training is effective in increasing critical self-management knowledge and self-efficacy in inner city adolescents, particularly females. PRACTICE IMPLICATIONS: Providers should screen carefully for symptoms and educate using developmentally appropriate training materials on ways to correctly monitor and manage symptom.

Perceptions and experiences underlying self-management and reporting of symptoms in teens with asthma.

BACKGROUND: Teens often have inadequate asthma self-management and control. However, little is known of their perceptions of or rationales for self-management behaviors. OBJECTIVES: To explore how teens self-manage asthma, including experiences, perceptions, responses to and reporting of symptoms. METHODS: A case-based, qualitative-descriptive design was used. Data were collected from minority and non-minority teens with controlled and uncontrolled asthma and their respective parents (N = 28). There were four data-collection points, including: (1) a primary teen interview; (2) parent interview; (3) 2-week self-management voice-diary; and (4) follow-up teen interview, incorporating symptom-response card-sorting to map symptoms and associated self-management responses. Seventy data sources were included in the analysis. RESULTS: Teens thought of their asthma symptoms as normal or unusual relative to their personal baseline symptom pattern; Those with uncontrolled asthma normalized higher levels of asthma symptoms than their counterparts with controlled asthma. Second, teens' decisions to treat symptoms of asthma with rescue medication were based on perceived benefits, burdens and accessibility of treatment balanced against perceived normalcy of symptoms. Teens with uncontrolled asthma had substantially higher treatment thresholds and delayed responses to symptoms compared to controlled peers. Third, teens never reported perceived normal symptoms of asthma to parents or providers, who were thus only aware of unusual or visible/audible symptoms. CONCLUSIONS: Teen's perceptions of symptoms and understanding of what is normal is the basis for self-management decisions. Improving self-management will likely entail modifying perceptions of symptoms and benefits/burdens of treatment to achieve healthier self-management patterns.

Computer-Assisted Concept Mapping: Visual Aids for Knowledge Construction.

BACKGROUND: Concept mapping is a visual representation of ideas that facilitates critical thinking and is applicable to many areas of nursing education. Computer-assisted concept maps are more flexible and less constrained than traditional paper methods, allowing for analysis and synthesis of complex topics and larger amounts of data. Ability to iteratively revise and collaboratively create computerized maps can contribute to enhanced interpersonal learning. However, there is limited awareness of free software that can support these types of applications. This educational brief examines affordances and limitations of computer-assisted concept maps and reviews free software for development of complex, collaborative malleable maps. RESULTS: Free software, such as VUE, XMind, MindMaple, and others, can substantially contribute to the utility of concept mapping for nursing education. CONCLUSIONS: Computerized concept-mapping is an important tool for nursing and is likely to hold greater benefit for students and faculty than traditional pen-and-paper methods alone. [J Nurs Educ. 2016;55(7):403-406.].

New approaches to qualitative interviewing: Development of a card sort technique to understand subjective patterns of symptoms and responses.

BACKGROUND: Ability to elicit individuals' perceptions of complex behavioral processes can be challenging, as it hinges not only upon the skill of the researcher, but also upon assumptions of a shared language and individuals' ability to recall, analyze, and effectively communicate events. In a case-based qualitative-descriptive study about teens' experiences of asthma self-management, we found that variations in terminology and descriptions of events, symptoms, and responses made it difficult to understand teens' experiences of asthma. In particular, teens' conceptualization of their asthma symptoms and self-management responses differed from situation to situation, from other teens in the study, from the interviewer, and from prior reports in the literature. These differences across many levels made it difficult to identify patterns in individual processes of self-management, and among teens in general.. OBJECTIVES: To address these challenges, we developed a card sorting activity to facilitate in-depth exploration of teens' experiences of asthma. DESIGN: Case-based qualitative description. SETTING: Teen-parent dyads (N=28) were recruited from the community, Emergency Department, Pediatric Pulmonary Department, and prior study subjects of a major medical center. METHODS: Teens first identified and then sequenced their own unique sets of asthma symptoms and self-management responses. Teens then developed contextually grounded narratives using the card sort they had created as a visual aid. RESULTS: This technique not only allowed us to bridge teen-interviewer communication barriers and develop shared terminology, but also resulted in a visible sequence of asthma symptoms and self-management responses. CONCLUSIONS: The card sort technique facilitated researcher-teen discussion and enabled comparison of self-management patterns across teens in our study. This technique is potentially useful for other areas of research exploring behavioral processes with complex and individual-specific experiences, in particular those involving sequences of events and self-management responses. This paper delineates the development, utility, and potential applications of the symptom-response card sorting technique for research and clinical practice.