A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder.

Functional neurological disorder (FND) is a complex condition involving an interaction of psychological, physiological, and social factors. Despite high utilization of medical services, people with FND often suffer from poor long-term health and psychosocial outcomes, and experience stigmatization and marginalization within the medical community. Health service psychologists are well positioned to help patients with FND through the lens of the biopsychosocial model of health. Psychologists can facilitate appropriate assessment and treatment, and advocate for the needs of patients diagnosed with FND within multidisciplinary teams. This article reviews best practices for assessment and treatment of individuals diagnosed with or suspected of having FND and presents some clinical and ethical challenges associated with this complex population.

The association between sleep and cognitive function in people with spinal cord injury (SCI).

PURPOSE/OBJECTIVE: While there is evidence in other clinical groups to suggest that sleep problems can negatively impact cognitive performance, this relationship has not yet been examined in people with spinal cord injury (SCI). Thus, we sought to examine the association between sleep and cognitive function in people with SCI. RESEARCH METHOD/DESIGN: Over the course of 7 days, 167 individuals with SCI completed daily subjective ratings of sleep (sleep quality, number of hours slept per night, and bedtime variability) and wore a wrist-worn device that continuously monitored autonomic nervous system (ANS) activity (i.e., blood volume pulse [BVP] signal and electrodermal activity [EDA] signal). At the end of this home monitoring period, participants completed a subjective rating of cognition and six objective cognitive tests. A series of multivariable linear regressions were used to examine associations between eight measures of sleep/ANS activity during sleep and eight cognitive variables. RESULTS: Subjective ratings of sleep were not related to either objective cognitive performance or self-reported cognitive function. However, there were some relationships between ANS activity during sleep and objective cognitive performance: lower BVP signal was associated with poorer performance on measures of processing speed, working memory, learning and long-term memory, and EDA signals were associated with poorer performance on a measure of executive function. CONCLUSIONS/IMPLICATIONS: Future work is needed to better understand the relationship of sleep, especially sleep physiology, and cognitive functioning for individuals with SCI, and how that may be similar or different to relationships in the general population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Intensive rehabilitation for functional motor disorders (FMD) in the United States: A review.

BACKGROUND: Higher levels of care in the form of intensive rehabilitation may be appropriate for select patients with a diagnosis of functional motor disorder (FMD). Intensive rehabilitation, as delivered through an outpatient day program or through admission to an inpatient rehabilitation facility, can offer a greater frequency and variety of integrated clinical services than most lower levels of care. OBJECTIVE: Higher levels of rehabilitation for FMD have not yet been well characterized in the literature. In this article, we will focus on the population of FMD patients who begin receiving care in the outpatient setting. METHOD: In this review, we describe a range of options for higher levels of FMD care, evaluate the supporting literature, and weigh the pros and cons of each approach. Several specific examples of intensive rehabilitation programs in the United States will be described. Finally, we will consider existing health systems barriers to each of these outpatient and inpatient higher levels of care. RESULTS: Within a stepped model of care, intensive outpatient day-programs and inpatient rehabilitation may be considered for individuals who present with complex, refractory motor deficits from FMD. For appropriately selected patients, a growing body of literature suggests that time-limited, goal-oriented intensive rehabilitation may provide an effective treatment avenue. CONCLUSION: It remains to be determined whether treatment in intensive care settings, while more costly in the short term, could lead to greater cost savings in the long term. The prospect of telemedicine rehabilitation for FND in terms of efficacy and cost also remains to be determined.

Daily Variation in Sleep Quality is Associated With Health-Related Quality of Life in People With Spinal Cord Injury.

OBJECTIVE: Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period. DESIGN: Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data. SETTING: Two academic medical centers. PARTICIPANTS: A total of 170 individuals with SCI (N=170). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day. RESULTS: Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day. CONCLUSIONS: Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI.

How Do Fluctuations in Pain, Fatigue, Anxiety, Depressed Mood, and Perceived Cognitive Function Relate to Same-Day Social Participation in Individuals With Spinal Cord Injury?

OBJECTIVE: This study aimed to examine same-day associations of pain, fatigue, depressed mood, anxiety, and perceived cognitive function with social participation in the daily lives of adults with spinal cord injury (SCI). DESIGN: Observational study used a combination of baseline surveys and 7 end-of-day (EOD) diaries. SETTING: General community. PARTICIPANTS: Individuals with SCI (N=168; mean age, 49.8y; 63% male, 37% female). MAIN OUTCOME MEASURES: Patient-Reported Outcomes Measurement Information System short form measures (Ability to Participate in Social Roles and Activities, Pain Intensity, Depression, Anxiety, Cognitive Function Abilities) were adapted for daily administrations as EOD diaries. RESULT: Results of multivariable model showed that daily increases in fatigue (B=-0.10; P=.004) and depressive symptoms (B=-0.25; P=<.001) and decreases in perceived cognitive function (B=0.11; P=<.001) were significantly related to worse same-day social participation. Daily fluctuations in anxiety and pain were unrelated to same-day social participation. CONCLUSIONS: This is the first study that shows within-person associations of common SCI symptoms with social participation in the daily lives of adults with SCI. Results from the current study may help to develop more effective individualized treatments of symptoms and symptom effect aimed at improving social participation.

The association between medication use and cognitive performance in people with SCI.

PURPOSE/OBJECTIVE: Polypharmacy is common in people with spinal cord injury (SCI). Given the high rates of medication use, and the complicated side effect profile of many of the medications that are regularly prescribed in people with SCI, we were interested in the association between the use of different classes of medications and cognitive function in these individuals. Research Method/Design: One-hundred and 73 people with SCI participated in an observational study. Self-reported medications were provided by participants. Participants also completed several cognitive tests designed to capture multiple aspects of cognition (processing speed, attention, working memory, learning, free-recall memory, delayed free recall memory, executive function), as well as a self-report measure that captures participant perceptions of cognitive function. A series of multivariable linear regressions were used to test for associations between medications and the seven measures of cognition. RESULTS: In general, there was not a robust relationship between medication use and cognitive function; the sole exception was an association between opioid use and subjective cognitive function. There was some preliminary support for an association between medication use, especially benzodiazepine and opioid analgesic use, and poorer cognitive performance. Specifically: Opioid analgesic use was associated with slowed processing speed, worse attention, poorer working memory, poorer executive function and more subjective cognitive complaints; benzodiazepine use was associated with slower processing speed, poorer working memory, and worse executive function; anticonvulsant use was related to worse delayed free recall memory; and the number of medication categories a person with SCI was taking was related to slower processing speed, and worse subjective cognitive function. Antidepressant, cannabis, skeletal muscle relaxant, sedative and stimulant use were not significantly related to cognitive performance, nor to subjective reports of cognitive function. CONCLUSIONS/IMPLICATIONS: Findings did not support a strong relationship between medication use and cognitive function in people with SCI. There is some preliminary support for an association between benzodiazepine use and cognitive performance, but this needs to be confirmed in future research. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effects of hypnosis, cognitive therapy, hypnotic cognitive therapy, and pain education in adults with chronic pain: a randomized clinical trial.

Chronic pain is a significant health problem worldwide with limited pharmacological treatment options. This study evaluated the relative efficacy of 4 treatment sessions each of 4 nonpharmacological treatments: (1) hypnotic cognitive therapy (using hypnosis to alter the meaning of pain); (2) standard cognitive therapy; (3) hypnosis focused on pain reduction, and (4) pain education. One hundred seventy-three individuals with chronic pain were randomly assigned to receive 4 sessions of 1 of the 4 treatments. Primary (pain intensity) and secondary outcome measures were administered by assessors unaware of treatment allocation at pretreatment, posttreatment, and 3-, 6-, and 12-month follow-up. Treatment effects were evaluated using analysis of variance, a generalized estimating equation approach, or a Fisher exact test, depending on the outcome domain examined. All 4 treatments were associated with medium to large effect size improvements in pain intensity that maintained up to 12 months posttreatment. Pretreatment to posttreatment improvements were observed across the 4 treatment conditions on the secondary outcomes of pain interference and depressive symptoms, with some return towards pretreatment levels at 12-month follow-up. No significant between-group differences emerged in omnibus analyses, and few statistically significant between-group differences emerged in the planned pairwise analyses, although the 2 significant effects that did emerge favored hypnotic cognitive therapy. Future research is needed to determine whether the significant differences that emerged are reliable.

The impact of stroke on psychological and physical function outcomes in people with long-term physical disability.

BACKGROUND: An increased number of people who have a long-term physical disability (LTPD) are aging. Similar to older adults without previous disability, individuals with LTPD may experience age-related comorbidities secondary to aging. A leading cause of disability in the United States among older adults is stroke. Limited evidence supports that individuals with LTPD are at higher risk of a stroke compared to those without disability. Stroke may negatively impact physical, cognitive, and/or psychosocial function. For those who have lived longer with LTPD, the impact of stroke may differ. OBJECTIVE: To determine the impact of stroke on health outcomes in people with LTPD. METHODS: Thirty-three individuals with both LTPD and self-reported stroke were identified in a national purposive sample of adults reporting physical disability associated with LTPD (Group A). Group A was compared to an age matched sample of 33 individuals with the same conditions but no stroke (Group B). Group A participants were also compared to national norms based on age cohort from a national sample of 182 stroke survivors (Group C). RESULTS: Age range of all participants = 65-74 years. Combine sample among three groups = 248. Group A did not differ from Group B. However, Group A reported significantly higher pain interference (p < .001), fatigue (p = .003), and decreased physical function (p < .001) than Group C. CONCLUSIONS: The study informs how the impact of acquiring another condition after living with a LTPD differs among a general stroke population and those who are living with LTPD.

Development of a resilience item bank and short forms.

PURPOSE: The purpose of this study was to develop a publicly available, psychometrically sound item bank and short forms for measuring resilience in any population, but especially resilience in individuals with chronic medical conditions or long-term disability. RESEARCH METHODS: A panel of 9 experts including disability researchers, clinical psychologists, and health outcomes researchers developed a definition of resilience that guided item development. The rigorous methodology used focus groups, cognitive interviews, and modern psychometric theory quantitative methods, including item response theory (IRT). Items were administered to a sample of people with chronic medical conditions commonly associated with disability (N = 1,457) and to a general population sample (N = 300) representative of the Unites States general population with respect to age, gender, race, and ethnicity. RESULTS: The final item bank includes 28 items calibrated to IRT with the scores on a T-metric. A mean of 50 represents the mean resilience in the general population sample. Four and eight item short forms are available, and their scores are highly correlated with the item bank score (r ≥ .94). Reliability is excellent across most of the resilience continuum. Initial analyses provide strong support for validity of the score. CONCLUSIONS: The findings support reliability and validity of the University of Washington Resilience Scale (UWRS) for assessing resilience in any population, including individuals with chronic health conditions or disabilities. It can be administered using computerized adaptive testing or by short forms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Relationship Between Fear of Falling and Physical Activity in People Aging With a Disability.

BACKGROUND: An estimated one billion people worldwide live with some form of disability and may face many challenges as they age, including increased fall risk. Understanding the risk factors linking falls, fear of falling, and activity restriction is critical for developing effective programs to increase activity levels among persons with disabilities. OBJECTIVES: To determine if differences exist in the level of physical activity in people with different types of conditions associated with disability and to investigate if fear of falling is associated with physical activity in individuals who are aging with a long-term disability. DESIGN: Cross-sectional retrospective design. SETTING: Community. PARTICIPANTS: A convenience sample of 1812 community-dwelling individuals who had one of four diagnoses: multiple sclerosis (MS), muscular dystrophy (MD), spinal cord injury (SCI), or post-polio syndrome (PPS). METHODS: Descriptive statistics, chi-square, and analysis of variance, followed by multivariate linear regression analysis were used to examine the association between physical activity status and fear of falling. MAIN OUTCOME MEASUREMENTS: Physical activity volume and fear of falling. RESULTS: After controlling for age, sex, duration of disability, and mobility level, there was variation across diagnostic groups (P < .001). People with SCI reported greater physical activity (M = 25.19) compared to other groups (MS: M = 18.70; MD: M = 21.83; PPS: M = 15.47). Patients with PPS had the greatest concerns about falling (M = 16.08), and patients with MS had the lowest (M = 13.12). Fear of falling was associated with physical activity (P < .001), which remained significant after controlling for diagnosis type, falls history, and level of mobility. CONCLUSION: Level of physical activity appears to vary among disability diagnoses. These results highlight the importance of addressing fear of falling in people with long-term disability because fear of falling is associated with physical activity.

Aging With Disability: Populations, Programs, and the New Paradigm An Introduction to the Special Issue.

Objective: The purpose of this article is to introduce a special issue dedicated to research at the intersection of aging and disability. Method: We provide some context for the importance of cross-disciplinary collaboration among aging and disability researchers and summarize the nine articles in this issue. Results: Articles in the special issue are centered around several overarching themes. These include meaningful social and community participation, goals and values in the context of disability, and the reach and effectiveness of programs and policies on rehabilitation and service utilization. Conclusion: As care models continue to merge aging and disability services, collaboration among traditional aging and disability research networks can lead to improved outcomes for adults aging with long-term disability.

Goal Pursuit, Goal Adjustment, and Pain in Middle-Aged Adults Aging With Physical Disability.

Objective: Aging with physical disability disrupts one's ability to achieve valued goals due to changes in symptoms and function. It is unclear how to cope optimally in this context. This study examined whether two possible strategies-tenacious goal pursuit (TGP) and flexible goal adjustment (FGA)-were associated with reduced pain interference and depressive symptoms and greater well-being, and protected against pain intensity, and FGA was more protective with increasing age and worse physical function. Method: Middle-aged adults with muscular dystrophy, multiple sclerosis, post-polio syndrome, or spinal cord injury (N = 874; MAGE = 58.3 years, range = 46-68; MDISEASEDURATION = 26.2 years, range = 2-67) completed two questionnaires, a year apart. Results: TGP and FGA use was associated with greater well-being. FGA use predicted decreased depressive symptoms. Concurrent use of both predicted decreased pain interference. Discussion: Adults with disability employ a variety of goal management strategies. Findings support TGP and FGA as potential intervention targets for healthy aging with disabilities.

Assessing Perceived Success in Valued Living in Individuals With Long-Term Physical Health Conditions.

Objective: To evaluate the reliability and validity of a brief measure of successful aging in a sample of adults with long-term health conditions. Method: The brief (eight-item) version of the valued living scale (VLS) and measures of pain intensity, pain interference, and depression were administered to 1,457 adults aging with one of four long-term health conditions. Results: Analyses indicated that the VLS items assessed two types of valued living domains: (a) a social and relational domain and (b) a health and productivity domain. The findings also supported the construct validity for the VLS items, in that both domains were associated significantly (and negatively) with the measures of pain intensity, pain interference, and depression. Discussion: The results provide preliminary support for the reliability and validity of the VLS items for assessing two important domains of successful aging in individuals with long-term health conditions.

Pilot intervention to promote tolerance for uncertainty in early multiple sclerosis.

PURPOSE/OBJECTIVE: The ability to tolerate uncertainty about the future may be foundational to positive psychological adjustment. Conversely, intolerance of uncertainty (IU) has been shown to be a vulnerability factor for anxiety and depression. One stressor with a very high degree of uncertainty about the future is a new diagnosis of multiple sclerosis (MS). However, few psychological interventions in MS have directly targeted IU. Research Method/Design: Forty-eight participants with early MS and moderate levels of distress were randomized to receive either 6 sessions of a brief psychological intervention designed to improve the ability to tolerate uncertainty (n = 23) or treatment as usual (TAU; n = 25). Measures of mood, IU, and MS acceptance were administered at baseline and about 8 weeks later. Intervention effects were tested via linear regression controlling for baseline levels. RESULTS: Participants were primarily Caucasian (85%) women (73%) and had lived with an MS diagnosis for an average of 376.3 days. Groups did not differ at baseline on most demographic or outcome variables. The intervention was well-tolerated, and most participants (82.6%) completed all 6 sessions and reported benefit. Postintervention, those in the intervention group demonstrated lower levels of IU and more MS acceptance relative to the TAU group. There was no effect of the intervention on global anxiety. Decreases in IU were associated with increases in MS acceptance (r = -.63). Effect sizes for these changes were moderate. CONCLUSIONS/IMPLICATIONS: These pilot results demonstrate that IU is responsive to a brief psychological intervention, and improvement with IU is associated with positive psychological outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Secondary health conditions and social role satisfaction in adults with long-term physical disability.

OBJECTIVE: Individuals living with physical disability due to early acquired or traumatic conditions often experience a range of psychological and physical health problems that are associated with their condition but are not directly caused by it. Known as "secondary health conditions," these problems can interact with existing functional limitations and other medical comorbidities to limit social participation. The current study assessed the concurrent and longitudinal associations between secondary health conditions, chronic medical comorbidities, and functional limitations, with a PROMIS® measure of social role participation. METHODS: A longitudinal survey study of community-dwelling adults with one of four chronic physical conditions (multiple sclerosis, muscular dystrophy, spinal cord injury, postpoliomyelitis syndrome). The baseline survey (T1) was mailed to 2041 individuals, and1862 baseline surveys were completed and returned (91% response rate). The follow-up survey (T2) was mailed roughly three years later; 1594 completed and returned the T2 survey (86% of T1 survey completers). RESULTS: Multiple linear regression analyses revealed that secondary health conditions, functional impairments, and chronic medical comorbidities accounted for 52% of the variance in satisfaction with social roles concurrently at T1. The amount of variance of change in satisfaction with social roles over the ∼3-year period accounted for by these variables was 3%. Functional limitations and more psychologically oriented secondary conditions were the strongest predictors of satisfaction with social roles. CONCLUSIONS: Findings suggest that, for people with disabilities, addressing psychologically oriented secondary health conditions may be as important as functional impairment in predicting long-term social health. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Associations among decisional autonomy, fatigue, pain, and well-being in long-term physical disability.

OBJECTIVE: Decisional autonomy-or sense of one's ability to make independent choices about one's life-is especially relevant to individuals who may feel their autonomy is limited due to physical challenges. Past work has found associations between measures of autonomy and quality of life (QoL) in individuals with disability and in older adults. However, it is less clear how decisional autonomy influences the impact of pain and fatigue severity on QoL, especially in adults aging with physical disability. This study examined the relationship of decisional autonomy to QoL and the extent to which autonomy moderates the association between symptom severity and QoL. METHOD: We used hierarchical linear regression models to examine the associations between autonomy, pain and fatigue, and quality of life in a sample of individuals with long-term disability. In 2 sets of models, we examined individuals reporting some level of fatigue (n = 1,060, Mage = 62.66, SD = 11.88) and some level of pain (n = 964, Mage = 62.79, SD = 11.69). RESULTS: We found that decisional autonomy significantly predicted QoL over and above other measures related to social participation. Decisional autonomy also weakly moderated the associations between fatigue and QoL and the associations between pain and QoL. CONCLUSIONS: The findings indicate that levels of decisional autonomy may be important to QoL in individuals aging with physical limitations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Identification of targets for improving access to care in persons with long term physical disabilities.

BACKGROUND: People with long-term physical disability (LTPD) continue to experience difficulties in accessing health care despite the focus of highlighting disparities in the last two decades. OBJECTIVES: To describe health care utilization, accommodations and barriers experienced while accessing health care, and reasons why individuals delay or skip health care among people with LTPD. METHODS: The current study was a part of a larger longitudinal survey administered to individuals with physical disability associated with one of four long-term conditions (MS; SCI; PPS; MD). Measures included demographics, health care utilization, barriers to health care, and reasons for delaying or skipping medical care from the sixth wave of data from 2015 to 2016. RESULTS: Roughly 90% of all participants (N = 1159) saw at least one medical provider within 12 months. The most encountered barrier participants reported experiencing within that time was an office that did not have a safe transfer device to move them to an exam table (69%). Participants' physical function, quality of life, status of living with a spouse, diagnostic condition, and sex (male) were significantly associated with endorsing a barrier in accessing health care. The inability to afford out of pocket expenses was the highest reported reason for delaying health care. CONCLUSIONS: People with LTPD access a variety of health care, including rehabilitation services, and continue to experience barriers when doing so. While understanding barriers individuals experience when accessing health care is important, it is equally important to document the type of care they delay or skip due to barriers.

Impact of secondary health conditions on social role participation for a long-term physical disability cohort.

For people living with long-term physical disability (LTPD) social participation may involve managing physical impairments and secondary health conditions (SHCs) that are not due to the pathophysiology of the LTPD diagnosis itself. Prior research found a negative relationship between SHCs and participation in social roles in people with spinal cord injury (SCI). We expand on this research by investigating the influence of SHCs on participation in social roles for people with one of four LTPDs, controlling for co-variates. We (1) evaluated the associations between SHCs and participation in social roles; and (2) determined whether SHCs on individuals' ability to participate in social roles varies by type of diagnosis in those aging with either SCI, muscular sclerosis, muscular dystrophy, or post-polio syndrome. Cross-sectional, secondary data analysis from a return-by-mail survey. N = 1,573. Data were analyzed with multiple linear regressions (hypothesis 1), and then three moderated regressions (hypothesis 2). After controlling for demographics, SHCs were associated with lower ability to participate in social roles and accounted for 48% of the variance (all p's <.001). The relationship between depression and social role participation was moderated by diagnosis, such that depression was more negatively associated with social participation among individuals with SCI (p = .020). Thus, SHC negatively impact participation in social roles.

Personal resource profiles of individuals with chronic pain: Sociodemographic and pain interference differences.

PURPOSE/OBJECTIVE: Previous studies have demonstrated important associations between personal resources and pain interference. Using latent profile analysis, the present study (a) identified subgroups of individuals with chronic pain who have different personal resource profiles; (b) explored sociodemographic differences among subgroups; and (c) examined how these subgroups differ in pain interference. Research Method/Design: Study 1 is based on daily diary and survey data from 220 individuals with fibromyalgia (FM). Study 2 is based on 4 annual surveys of 483 individuals with long-term neurological/neuromuscular disease or injury, and chronic pain. Modifiable personal resource variables including sense of resilience, social support, pain acceptance, and sleep quality were included in latent profile analyses. RESULTS: Three subgroups were identified in both studies: High, Moderate, and Low Personal Resource groups. In both studies, annual income level was significantly different among subgroups. Study 1 results showed a significant between-groups difference in pain interference across 21-days only between High and Moderate Personal Resource groups controlling for the level of pain intensity and depressive symptoms. In Study 2, however, all subgroups were significantly different with respect to their levels of pain interference at baseline over and above various covariates, with the Low Personal Resource group reporting the highest level of pain interference at baseline. These baseline differences remained stable over 4 years. CONCLUSIONS/IMPLICATIONS: The findings suggest a robust association between economic disparity and personal resource profiles among individuals with chronic pain. The role of different personal resource profiles in pain interference appears to differ by chronic pain condition. (PsycINFO Database Record (c) 2019 APA, all rights reserved).