Emerging From the Haze™: Pilot Feasibility Study Comparing Two Virtual Formats of a Cognitive Rehabilitation Intervention.

OBJECTIVES: To gather feasibility and preliminary data comparing two virtual delivery methods for providing Emerging From the Haze™ (Haze) to cancer survivors compared to waitlist control (WLC). SAMPLE & SETTING: Eligible participants (N = 93) reported cancer-related cognitive impairment following chemotherapy for stage I-III solid tumors, Hodgkin lymphoma, or non-Hodgkin lymphoma. METHODS & VARIABLES: A three-arm randomized design was used to compare virtual live group presentation of Haze sessions, virtual prerecorded Haze group sessions, and WLC. Data were collected at baseline, week 10, and week 14. RESULTS: Feasibility was demonstrated. Significant cognitive function improvement at week 10 versus WLC was reported for the live group, and clinical improvement was reported for the prerecorded group. The prerecorded group reported significant improvement at week 14 versus WLC in physical activity, sleep, and health-related quality of life. IMPLICATIONS FOR NURSING: Additional pilot and feasibility evidence for cognitive rehabilitation interventions was demonstrated. Prerecorded Haze delivery shows potential for clinical effectiveness and scalability. Future multisite research is warranted.

Post-traumatic stress symptoms, post-traumatic stress disorder, and post-traumatic growth among cancer survivors: a systematic scoping review of interventions.

The detrimental effects of Post-Traumatic Stress Symptoms (PTSS) and Post-Traumatic Stress Disorder (PTSD) and the benefits of Post-Traumatic Growth (PTG) are well established for cancer survivors. Increased cancer survival rates necessitate an understanding of how these two paradoxical outcomes, PTSS/PTSD and PTG, are targeted through interventions. This systematic scoping review aims to (a) examine existing evidence on interventions targeting PTSS/PTSD and/or PTG among cancer survivors and (b) identify knowledge gaps to inform future research. Following the six steps of a scoping review, 76 articles met the inclusion criteria. Quantitative articles were examined using descriptive analysis. Frequency counts of the collated data were tabulated into summary tables. Qualitative articles were reviewed using meta-synthesis. Most articles were quantitative (n = 52) and targeted PTG (n = 68) through promising intervention approaches such as psychotherapy, mindfulness, physical activity, and psilocybin-assisted therapy. Three key implications for future research and practice were synthesized: (1) mechanistic considerations for intervention design that provide a roadmap for rigorous and theoretically-grounded research; (2) the need for improved representation of cancer survivors in trials; and (3) potential facilitators of intervention efficacy. Together, these findings can direct future research to optimize interventions to reduce PTSS/PTSD and promote PTG achievement among cancer survivors.

A 6-Week Program to Strengthen Resiliency Among Women With Metastatic Cancer: A Randomized Clinical Trial.

PURPOSE: The objective of this study was to evaluate the effect of an intervention (Growing Resilience And CouragE; GRACE) on spiritual well-being, quality of life, and general well-being in women with metastatic cancers reporting existential or spiritual distress. PATIENTS AND METHODS: Prospective, randomized, wait-list control clinical trial. Women with metastatic cancer experiencing existential or spiritual concerns were randomized to GRACE or waitlist control. Survey data were collected at baseline, end of program, and 1-month follow-up. Participants included English-speaking women, 18 or older, with metastatic cancer, existential or spiritual concerns, and reasonable medical stability. Eighty-one women were assessed for eligibility; 10 were excluded (not meeting exclusion criteria, refusal to participate, and death). The primary outcome was spiritual well-being measured pre- and post-program. Secondary measures assessed quality of life, anxiety, depression, hopelessness, and loneliness. RESULTS: Seventy-one women (aged 47-72) were enrolled (GRACE n = 37, waitlist control n = 34). GRACE participants demonstrated significant improvements in spiritual well-being compared to control at end of program (parameter estimate (PE), 16.67, 95% CI, 13.17, 20.16) and 1-month follow-up (PE, 10.31, 95% CI, 6.73, 13.89). Additionally, significant improvements were demonstrated in quality of life at the end of program (PE, 8.51, 95% CI, 4.26, 12.76) and 1-month follow-up (PE, 6.17, 95% CI, 1.75, 10.58). GRACE participants also demonstrated improved depression and hopelessness at follow-up, as well as improved anxiety. CONCLUSIONS: Findings suggest the value of evidence-based psychoeducational and experiential interventions for improving the well-being and quality of life of women with advanced cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02707510.

The impact of positive reinforcement on teamwork climate, resiliency, and burnout during the COVID-19 pandemic: The TEAM-ICU (Transforming Employee Attitudes via Messaging strengthens Interconnection, Communication, and Unity) pilot study.

Burnout is an internationally recognized occupational phenomenon that negatively impacts the healthcare workforce and its recipients. The aim of this pilot study was to test whether positive reinforcement and integrating a language of support among co-workers can enhance resiliency, facilitate psychological wellness, and encourage hope. This embedded mixed methods prospective, behavioral, interventional study evaluated the effects of positive feedback on wellness among intensive care unit clinicians during the COVID-19 pandemic in a single center, quaternary care medical center. The deliberate positive feedback paradigm has the potential to augment resiliency and improve attitudes toward a teamwork climate. The routine use of deliberate positivity may represent a scalable, low-cost initiative to enhance wellness in a healthcare organization.

Feasibility Pilot Study of a Virtual Intervention for Survivors With Decreased Perceived Cognitive Function After Cancer Treatment.

OBJECTIVES: Many cancer survivors report issues with cognitive function following diagnosis and treatment. The purpose of this single-arm pilot study was to test the feasibility and acceptability of virtual delivery of a cognitive rehabilitation intervention for participants in virtual groups. SAMPLE & SETTING: 37 adult cancer survivors reporting impaired cognitive function following primary treatment were enrolled from Cedars-Sinai Medical Center and affiliates, the University of Kansas Cancer Center, and the Masonic Cancer Alliance. METHODS & VARIABLES: Two cohorts attended six weekly virtual sessions and completed pre- and postintervention patient-reported outcome questionnaires designed to measure perceived cognitive function, loneliness, and determinants of behavior change for exercise, sleep, and mindfulness. RESULTS: Postintervention scores for perceived cognitive function, determinants of behavior change, and loneliness ratings significantly improved. IMPLICATIONS FOR NURSING: Evidence continues to build in support of cognitive rehabilitation interventions for cancer survivors. Nurses play an important role in terms of patient identification, participation, and facilitation.

Identification of Functional Limitations and Discharge Destination in Patients With COVID-19.

OBJECTIVES: The objectives of this study were to identify functional limitations in patients with coronavirus 2019 (COVID-19) admitted to acute care hospitals; to evaluate functional limitations by demographic, medical, and encounter characteristics; and to examine functional limitations in relation to discharge destination. DESIGN: and Setting:This is a cross-sectional, retrospective study of adult patients with COVID-19 who were discharged from 2 different types of hospitals (academic medical center and a community hospital) within 1 health care system from January 1 to April 30, 2020. PARTICIPANTS: Patients were identified from the Cedars-Sinai COVID-19 data registry who had a new-onset positive test for severe acute respiratory syndrome coronavirus 2. A total of 273 patients were identified, which included 230 patients who were discharged alive and 43 patients who died and were excluded from the study sample. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional limitations in patients with COVID-19 in acute care hospitals and the predictors for discharge disposition. RESULTS: A total of 230 records were analyzed including demographic, encounter, medical, and functional variables. In a propensity score-matched cohort based on age and comorbidity, 88.2% had functional physical health deficits, 72.5% had functional mental health deficits, and 17.6% experienced sensory deficits. In the matched cohort, individuals discharged to an institution experienced greater physical (62.7% vs 25.5%, P<.001) and mental health (49.0% vs 23.5%, P=.006) deficits than patients discharged home. Marital status (odds ratio, 3.17; P=.011) and physical function deficits (odds ratio, 3.63; P=.025) were associated with an increase odds ratio of discharge to an institution. CONCLUSIONS: This research highlights that functional status is a strong predictor for discharge destination to an institution for patients with COVID-19. Patients who were older, in the acute care hospital longer, and with comorbidities were more likely to be discharged to an institution. Rehabilitation is a significant aspect of the health care system for these vulnerable patients. The challenges of adjusting the role of rehabilitation providers and systems during the pandemic needs further exploration. Moreover, additional research is needed to look more closely at the many facets and timing of functional status needs, to shed light in use of interdisciplinary rehabilitation services, and to guide providers and health care systems in facilitating optimal recovery and patient outcomes.

Sustained quality-of-life improvements over 10 years after deep brain stimulation for dystonia.

BACKGROUND: Little is known about the quality of life of people with dystonia and DBS beyond 5 years. The objectives of this study were (1) to examine the long-term quality-of-life outcomes in a large cohort of people with dystonia and DBS, (2) to determine the incidence of stimulation-induced parkinsonism, and (3) to elucidate the potential long-term cognitive impact of DBS in this cohort. METHODS: Fifty-four subjects with dystonia and DBS for more than 5 years were contacted via social media and were offered to complete a quality-of-life survey comparing current-day life and life prior to DBS. The primary study outcomes were the Short Form survey, a parkinsonian symptoms questionnaire, the Telephone Montreal Cognitive Assessment, and the Measurement of Every Day Cognition. RESULTS: Thirty-seven of 54 subjects consented to the study. Average age was 39.7 ± 16.6 years, 16 were female, and 23 were DYT1+. Average time from implantation was 10.5 years. Average total Short Form survey scores improved, from 43.7 pre-DBS to 69.5 current day (P < 0.0005). Mean total self-reported parkinsonian symptom score was 13.8 ± 14.7, with worsening balance and hypophonia the most common. Average Telephone Montreal Cognitive Assessment was 20.1 ± 1.6, with 3 of 29 scores (10.3%) in the impaired range (score of 18 or less). Average total Every Day Cognition score was 1.25 ± 0.35, with 3 subjects (10.3%) scoring in the range of impaired cognition (>1.81). CONCLUSIONS: DBS for dystonia results in long-term quality-of-life improvements that persist on average 10 years or more after surgery. The prevalence of stimulation-induced parkinsonism and cognitive impairment is low. © 2018 International Parkinson and Movement Disorder Society.

Neurocognition and Cerebral Lesion Burden in High-Risk Patients Before Undergoing Transcatheter Aortic Valve Replacement: Insights From the SENTINEL Trial.

OBJECTIVES: The authors sought to determine baseline neurocognition before transcatheter aortic valve replacement (TAVR) and its correlations with pre-TAVR brain imaging. BACKGROUND: TAVR studies have not shown a correlation between diffusion-weighted image changes and neurocognition. The authors wanted to determine the extent to which there was already impairment at baseline that correlated with cerebrovascular disease. METHODS: SENTINEL (Cerebral Protection in Transcatheter Aortic Valve Replacement) trial patients had cognitive assessments of attention, processing speed, executive function, and verbal and visual memory. Z-scores were based on normative means and SDs, combined into a primary composite z-score. Brain magnetic resonance images were obtained pre-TAVR on 3-T scanners with a T2 fluid-attenuated inversion recovery (FLAIR) sequence. Scores ≤-1.5 SD below the normative mean (7th percentile) were considered impairment. Paired t tests compared within-subject scores, and chi-square goodness-of-fit compared the percentage of subjects below -1.5 SD. Correlation and regression analyses assessed the relationship between neurocognitive z-scores and T2 lesion volume. RESULTS: Among 234 patients tested, the mean composite z-score was -0.65 SD below the normative mean. Domain scores ranged from -0.15 SD for attention to -1.32 SD for executive function. On the basis of the ≥1.5 SD normative reference, there were significantly greater percentages of impaired scores in the composite z-score (13.2%; p = 0.019), executive function (41.9%; p < 0.001), verbal memory (p < 0.001), and visual memory (p < 0.001). The regression model between FLAIR lesion volume and baseline cognition showed statistically significant negative correlations. CONCLUSIONS: There was a significant proportion of aortic stenosis patients with impaired cognition before TAVR, with a relationship between baseline cognitive function and lesion burden likely attributable to longstanding cerebrovascular disease. These findings underscore the importance of pre-interventional testing and magnetic resonance imaging in any research investigating post-surgical cognitive outcomes in patients with cardiovascular disease.

Deep Brain Stimulation and Nonmotor Symptoms.

Deep brain stimulation (DBS) is currently the treatment of choice for advanced Parkinson's disease (PD). Several brain targets, including the subthalamic nucleus and the globus pallidus internus, have been successfully employed, with excellent motor outcomes. Despite less established knowledge, DBS may be a powerful tool for managing a wide variety of nonmotor symptoms (NMS) in PD patients, either directly or indirectly due to motor benefit or reduction of dopaminergic drug load. After an assessment of global nonmotor outcomes of DBS, as measured by currently available clinical scales and questionnaires, this chapter will address DBS effects on four main NMS categories: neurobehavioral, including cognitive and neuropsychiatric symptoms, autonomic dysfunction, including orthostatic hypotension, constipation, and urinary dysfunction, sleep disturbances, including insomnia, REM sleep behavior disorder, and restless leg syndrome, to conclude with sensory symptoms, mainly focusing on pain. An overall positive impact of DBS on most NMS emerges from the reviewed studies. However, current opinion on the effect of DBS on NMS in PD needs to be tempered by the relatively low number of cases and the lack of large, controlled, specifically designed studies for most NMS categories.

Pragmatic communication abilities in children and adults: implications for rehabilitation professionals.

PURPOSE: The purpose of this study is to provide a review of pragmatic communication ability and its disorders, as a resource for rehabilitation team members. This review is a product of the Joint Committee on Interprofessional Relations Between the American Speech-Language-Hearing Association and Division 40: Society for Clinical Neuropsychology of the American Psychological Association. METHOD: Review of the literature and expert opinion. RESULTS: We summarize key theoretical frameworks that guide assessment of pragmatic communication ability, describe the developmental progression of pragmatic skills and expectations for children and adults, provide an overview of pragmatic communication disorders, and discuss current assessment approaches. CONCLUSIONS: An understanding of pragmatic communication disorders may assist all rehabilitation team members, as impairments in this domain may have significant effects on rehabilitation progress and outcomes. Implications for Rehabilitation Pragmatic communication ability is the ability to use language in context, beyond understanding and expressing basic word meanings (semantics) in the correct grammatical forms (syntax). Pragmatic communication deficits have been documented in many of the populations frequently referred for rehabilitation, and can affect both progress during rehabilitation and outcomes from treatment. A broader understanding of pragmatic communication functions can help team members identify a patient's strengths and limitations, inform treatment planning, and improve communication among healthcare professionals, thereby contributing to improved outcomes for patients and their families.

A conceptual model for vision rehabilitation.

Vision impairments are highly prevalent after acquired brain injury (ABI). Conceptual models that focus on constructing intellectual frameworks greatly facilitate comprehension and implementation of practice guidelines in an interprofessional setting. The purpose of this article is to provide a review of the vision literature in ABI, describe a conceptual model for vision rehabilitation, explain its potential clinical inferences, and discuss its translation into rehabilitation across multiple practice settings and disciplines.

The rationale driving the evolution of deep brain stimulation to constant-current devices.

OBJECTIVE: Deep brain stimulation (DBS) is an effective therapy for the treatment of a number of movement and neuropsychiatric disorders. The effectiveness of DBS is dependent on the density and location of stimulation in a given brain area. Adjustments are made to optimize clinical benefits and minimize side effects. Until recently, clinicians would adjust DBS settings using a voltage mode, where the delivered voltage remained constant. More recently, a constant-current mode has become available where the programmer sets the current and the stimulator automatically adjusts the voltage as impedance changes. METHODS: We held an expert consensus meeting to evaluate the current state of the literature and field on constant-current mode versus voltage mode in clinical brain-related applications. RESULTS/CONCLUSIONS: There has been little reporting of the use of constant-current DBS devices in movement and neuropsychiatric disorders. However, as impedance varies considerably between patients and over time, it makes sense that all new devices will likely use constant current.

The impact of STN deep brain stimulation on speech in individuals with Parkinson's disease: the patient's perspective.

BACKGROUND: Speech disturbance is highly prevalent and disabling for individuals with Parkinson's disease (PD). Deep brain stimulation (DBS) has been found to adversely impact speech in a number of individuals with PD. This study investigated the differential speech profiles between individuals with PD with and without DBS from the patient's perspective. METHODS: A cross sectional research design was used. A total of 758 individuals with PD participated in this study, including 287 individuals with DBS and 471 individuals without DBS. Participants completed the Voice Handicap Index (VHI) and additional questions regarding speech symptoms and the impact of speech on social interaction. RESULTS: Independent of age and disease duration, there were statistically significant differences in perceived speech disturbance severity between the STN-DBS group and Non-DBS group, with the DBS group reporting more severe symptoms as well as more significant symptom interference with social interaction and with daily experiences encountered relating to functional, physical, and emotional issues of a voice disorder (VHI). Low volume was the "most common" speech symptom for all individuals with PD patients across both age (younger and older) and disease duration (6-10 years and 11+ years) cohorts. DBS had the greatest adverse impact on "slurred speech." CONCLUSION: DBS therapy's contribution to speech disturbance is gaining more attention, and the speech symptoms ensuing from and/or being exacerbated by DBS are in the incipient stages of being investigated. Implications for DBS therapy on perceived quality of life are discussed.

The impact of inpatient rehabilitation on function and survival of newly diagnosed patients with glioblastoma.

OBJECTIVE: To examine the impact of an inpatient rehabilitation program on functional improvement and survival among patients with newly diagnosed glioblastoma multiforme (GBM) who underwent surgical resection of the brain tumor. DESIGN: A retrospective cohort study of newly diagnosed patients with GBM between 2003 and 2010, with survival data updated through January 23, 2013. SETTING: An urban academic nonprofit medical center that included acute medical and inpatient rehabilitation. PARTICIPANTS: Data for newly diagnosed patients with GBM were examined; of these patients, 100 underwent inpatient rehabilitation after resection, and 312 did not undergo inpatient rehabilitation. MAIN OUTCOME MEASUREMENTS: Overall functional improvement and survival time for patients who participated in the inpatient rehabilitation program. RESULTS: A total of 89 patients (93.7%) who underwent inpatient rehabilitation improved in functional status from admission to discharge, with the highest gain observed in mobility (96.8%), followed by self-care (88.4%), communication/social cognition (75.8%), and sphincter control (50.5%). The median overall survival among inpatient rehabilitation patients was 14.3 versus 17.9 months for patients who did not undergo inpatient rehabilitation (P = .03). However, after we adjusted for age, extent of resection, and Karnofsky Performance Status Scale scores, we found no statistical difference in the survival rate between patients who did and did not undergo inpatient rehabilitation (hazard ratio [HR], 0.84; P = .16). Among the patients who underwent inpatient rehabilitation, older age (HR, 2.24; P = .0006), a low degree of resection (HR, 1.67; P = .02), and lack of a Stupp regimen (HR, 1.71; P = .05) were associated with greater hazard of mortality. CONCLUSIONS: Patients who undergo inpatient rehabilitation demonstrate significant functional improvements, primarily in the mobility domain. Confounder adjusted multivariate analysis showed no survival difference between patients who did and did not undergo inpatient rehabilitation; this finding suggests that a structured inpatient rehabilitation program may level the survival field in lower-functioning patients who otherwise may be faced with a dismal prognosis.

Randomized controlled trial of peer mentoring for individuals with traumatic brain injury and their significant others.

OBJECTIVES: To examine the efficacy of a peer-mentoring program for persons with traumatic brain injury (TBI) and their significant others, and to determine the relationship of this mentoring program to 3 main outcomes: (1) emotional well-being; (2) post-TBI quality of life; and (3) community integration. DESIGN: Randomized controlled trial. SETTING: Midwestern rehabilitation hospital. PARTICIPANTS: Persons with TBI (n=96) and significant others/caregivers (n=62). INTERVENTIONS: Persons with TBI and friends/caregivers who knew the person prior to their injury were randomly assigned to a treatment (mentored) or no-treatment (no mentoring) control group immediately prior to discharge from the rehabilitation unit and were mentored for up to 2 years. MAIN OUTCOME MEASURES: Peer Mentoring Questionnaire; Brief Symptom Inventory-18; Family Assessment Device; Coping Inventory for Stressful Situations; Short Michigan Alcohol Screening Test; Medical Outcomes Study 12-Item Short-Form Health Survey; and Community Integration Measure. RESULTS: Eighty-eight percent of individuals who were involved in the mentoring program reported positive experiences. t tests revealed that among persons with TBI, individuals who received mentoring had significantly better behavioral control and less chaos in the living environment (P=.04), lower alcohol use (P=.01), less emotion-focused (P=.04) and avoidance coping (P=.03), and good physical quality of life (P=.04) compared with those who did not receive mentoring. Among significant others, mentored individuals demonstrated greater community integration (P=.03) than the nonmentored control group. CONCLUSIONS: Mentoring can be an effective way to benefit mood and healthy coping after TBI, and it can help to prevent maladaptive behaviors, such as substance abuse and behavioral dyscontrol, in the living situation.

Assessment of executive functioning in brain injury: collaboration between speech-language pathology and neuropsychology for an integrative neuropsychological perspective.

BACKGROUND: Executive functioning (EF) deficits are common sequelae of traumatic brain injury (TBI). These deficits extend beyond the acute stages of recovery and pose a significant challenge in rehabilitation efforts. Current theories of EF propose a multidimensional construct. This paper provides an integrative theoretical framework with interactive dimensions for the assessment and treatment of EF that can assist the interdisciplinary team to successfully manage EF deficits secondary to TBI. METHODS: This paper is a review of pertinent literature related to assessment of EF. It concludes with a case presentation that illustrates the utility of the proposed theoretical framework in the rehabilitation context. CONCLUSIONS: Formal neuropsychological, standardized psychometric measures and informal clinical observations, particularly as they relate to contextual assessment, should be incorporated in order to effectively assess EF difficulties in survivors of TBI. The paper concludes with recommendations for effective assessment and treatment of EF by the interdisciplinary team consisting of speech-language pathologists and neuropsychologists.

Perceived roles and collaboration between neuropsychologists and speech-language pathologists in rehabilitation.

The purpose of the current study was to determine perceptions of neuropsychologists (NPs) and speech-language pathologists (SLPs) regarding each other's roles in the rehabilitation setting, and to assess the type and extent of collaborations. Participants were 311 SLPs and 77 NPs working in a rehabilitation setting. Results indicated a great deal of overlap between the roles of SLPs and NPs. While there was much agreement about roles, misperceptions were evident with regard to some of the domains of assessment and treatment. A need for increased collaboration on planning assessments and treatment was evident. The results suggest the need for training of both disciplines in interdisciplinary collaboration and in roles of rehabilitation team members.

Comparing functional status and community integration in severe penetrating and motor vehicle-related brain injuries.

OBJECTIVE: To examine the functional status of persons surviving a severe penetrating traumatic brain injury (TBI) resulting from a gunshot wound who require inpatient rehabilitation. DESIGN: Data were collected prospectively at 4 different time periods: rehabilitation admission and discharge and year 1 and year 2 postinjury. SETTING: Rehabilitation hospital within a Traumatic Brain Injury Model System. PARTICIPANTS: Forty-five persons with severe penetrating brain injury and 45 persons involved in a motor vehicle crash (MVC). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Disability Rating Scale (DRS), FIM instrument, and Community Integration Questionnaire (CIQ). RESULTS: Results indicated functional improvements for both the penetrating and motor vehicle severe TBI groups on the DRS and the FIM from rehabilitation admission to discharge. Follow-up data at 1 and 2 years postinjury revealed continued improvements on the DRS and FIM measures for both groups, with the greatest improvement in recovery during the first year. In addition, improved community reintegration emerged between 1 and 2 years postinjury for both groups, as measured by the CIQ. There was a small significant difference on the outcome measures between the 2 groups in the course of their recovery. CONCLUSIONS: Persons who survive severe penetrating brain injuries and who require inpatient rehabilitation may show continuing improvement in functioning over time. For persons receiving inpatient rehabilitation services, initial improvement is most likely to occur during the hospital stay and continue postinjury, with the largest improvement in the first year after injury. Community reintegration can also be expected over time. One can expect similar outcomes for individuals who sustain a severe penetrating brain injury and a severe brain injury ensuing from an MVC.