Alison Cogan

Supporting Our Military Families: A Case for a Larger Role for Occupational Therapy in Prevention and Mental Health Care

More than 2 million U.S. military servicemembers have deployed to Afghanistan or Iraq since September 11, 2001. Unlike during prior conflicts, many servicemembers leave spouses and children behind. Long, multiple deployments cause strain on family at home, with new challenges arising when servicemembers return from combat and reintegrate into family and civilian life. In World Wars I and II, occupational therapy practitioners played a significant role in supporting servicemember reintegration. However, their presence in program delivery in this practice area is limited. Occupational therapy researchers and practitioners can make a valuable contribution by helping families tailor daily activities and routines to address challenges and optimize health and wellness. However, barriers such as reimbursement for services, workforce availability, and access to military families have limited the professions full engagement. Advocacy is needed to help establish occupational therapy as a key component of the mental and preventive health care teams serving military servicemembers.

Occupational Needs and Intervention Strategies for Military Personnel with Mild Traumatic Brain Injury and Persistent Post-Concussion Symptoms: A Review

Mild traumatic brain injury (mTBI), also known as concussion, has been labeled the “signature injury” of the wars in Iraq and Afghanistan. A subset of military personnel with mTBI experience ongoing symptoms well beyond the normal recovery window. While much research has been dedicated to understanding the etiology and severity of the symptoms, very little has assessed how long-term symptoms impact participation in daily life. A scoping study of the occupational science and occupational therapy literature was conducted to ascertain the current state of research on the impact of mTBI on participation in daily life activities, as well as occupational therapy interventions for mTBI. Although the emphasis in this article is on military personnel with mTBI, studies on civilians with mTBI were included in the review as research with military populations is extremely limited. Based on the literature reviewed, the author suggests a role for occupational science research and occupational therapy practice in meeting the occupational needs of military service members with persistent symptoms after mTBI.

Systematic review of behavioral and educational interventions to prevent pressure ulcers in adults with spinal cord injury

Objective: To investigate the efficacy of behavioral or educational interventions in preventing pressure ulcers in community-dwelling adults with spinal cord injury (SCI). Data sources: Cochrane, Clinical Trials, PubMed, and Web of Science were searched in June 2016. The search combined related terms for pressure ulcers, spinal cord injury, and behavioral intervention. Each database was searched from its inception with no restrictions on year of publication. Review methods: Inclusion criteria required that articles were (a) published in a peer-reviewed journal in English, (b) evaluated a behavioral or educational intervention for pressure ulcer prevention, (c) included community-dwelling adult participants aged 18 years and older with SCI, (d) measured pressure ulcer occurrence, recurrence, or skin breakdown as an outcome, and (e) had a minimum of 10 participants. All study designs were considered. Two reviewers independently screened titles and abstracts. Extracted information included study design, sample size, description of the intervention and control condition, pressure ulcer outcome measures, and corresponding results. Results: The search strategy yielded 444 unique articles of which five met inclusion criteria. Three were randomized trials and two were quasi-experimental designs. A total of 513 participants were represented. The method of pressure ulcer or skin breakdown measurement varied widely among studies. Results on pressure ulcer outcomes were null in all studies. Considerable methodological problems with recruitment, intervention fidelity, and participant adherence were reported. Conclusions: At present, there is no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure ulcer occurrence in adults with SCI.

Lifestyle intervention for adults with spinal cord injury: Results of the USC–RLANRC Pressure Ulcer Prevention Study

Context/Objective: Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI. Design: A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group. Setting: Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County. Participants: Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group. Interventions: The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts. Outcome Measures: Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures. Results: Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants. Conclusions: Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect. Trial Registration: ClinicalTrials.gov NCT01999816

Community reintegration: Transition between the figured worlds of military and family life

ABSTRACT This paper argues the benefits of characterizing occupational transitions as movement between figured worlds, which are socially constructed units that are characterized by particular people and activities, and that shape identities. Further, positive withdrawal, which is a purposeful decision to limit participation when the requirements of engaging surpass self-perceived ability, describes limited engagement with a figured world. To illustrate the utility of this lens, the community reintegration of military service members as they finish deployment and return to family and community life is explored. The figured worlds of military and family are drawn from first person accounts of deployment and reintegration experiences from the perspectives of both service members and spouses. The constructs of figured world and positive withdrawal are found to be useful ways to describe community reintegration for both service members and families and the complex shifts in identity associated with the transition process. The framework presented expands on the occupational science literature by presenting a framework for non-linear, bidirectional occupational transitions in which individuals return to familiar settings rather than enter novel ones. The constructs of figured world and positive withdrawal can contribute to future theory development and research with populations that experience similar occupational transitions.

Deciphering participation: an interpretive synthesis of its meaning and application in rehabilitation

Abstract Purpose: Participation is widely recognized as an important outcome for rehabilitation. However, it lacks a universally accepted definition. The purpose of this review is to synthesize the literature about participation in rehabilitation in order to clarify the term and increase its usefulness for rehabilitation providers and researchers. Methods: We undertook an interpretive synthesis of the literature, drawing from a broad and varied selection of the vast number of publications on the subject of participation. The search and analysis was iterative and continued until saturation of themes was achieved. Results and Conclusions: Seventy-six articles were included in our analysis. We argue that three essential dimensions – performance, subjective experience, and interpersonal connection – constitute participation. We further divide participation into community-based and interventional contexts. Interventional participation is circumscribed by the treatment setting, whereas community-based encompasses all other areas. Participation in either interventional or community-based contexts is largely determined by the available opportunities from which a person can choose, with such opportunities affected by conditions that are either internal or external to the individual. As defined in this framework, participation is not inherently good or bad; rather, its effect is determined by a person’s unique life circumstances and the impact may not always be apparent. We posit this model as a resource for future research as well as clinical reasoning. Implications for Rehabilitation The often tacit assumption that increasing participation is a desirable outcome needs to be challenged and considered in each patient’s life situation. Treatment settings constitute a unique context in which patients participate. Intervention goals should be clearly connected with patients’ personal goals for community-based participation.

Building a Framework for Implementing New Interventions

Implementation into real-world practice of interventions previously studied in randomized controlled trials is an ongoing challenge. In this article, we describe the methodology we used for the first phase of a project for the implementation and outcomes assessment of an occupational therapy pressure ulcer prevention intervention for people with spinal cord injury in the Veterans Health Administration. This first phase of the project was guided by practice-based evidence research methodology and resulted in an intervention manual tailored to meet the needs of Veterans and the establishment of a system for documenting and monitoring care processes, patient characteristics, and intervention outcomes. This system, in turn, will provide the data-gathering template for the next phase in which the beneficial effects of the intervention will be assessed. We conclude by recommending that clinicians explore the utility of this approach for the implementation of other novel interventions.

White matter abnormalities in blast mild traumatic brain injury in the military

ABSTRACT Mild traumatic brain injury (mTBI) has been labeled the “signature injury” of the wars in Iraq and Afghanistan, and approximately half of mTBIs that occur in combat are due to explosive blasts. The rapid change in pressure that results from an explosion may make blast injury distinct from mTBI due to other causes. Persistent symptoms following blast mTBI may be related to white matter damage that has recently been identified using innovative neuroimaging techniques, such as diffusion tensor imaging (DTI). By comparing the DTI findings in blast mTBI to studies of the effects of white matter structure on functional performance, hypotheses can be developed about the implications of the injury for engagement in occupation. Incorporation of neuroscience evidence about the effects of blast mTBI may provide objective evidence of underlying damage that correlates with deficits in occupational engagement of military service members and veterans who are affected by these injuries.