Angela L.H. Buffington

Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis.

This article provides an overview of the emerging literature on biopsychosocial assessment and treatment for two of the most common forms of arthritis: osteoarthritis and rheumatoid arthritis. The article is divided into 3 parts. In the 1st part, the basic elements of the biopsychosocial approach to assessing and treating persons having arthritis is described. In the 2nd part, the authors evaluate studies of biopsychosocial approaches to the assessment of arthritis pain and disability. Six research areas are reviewed: learned helplessness, depression, stress, pain coping, self-efficacy, and the social context of arthritis. The 3rd part of the article reviews studies that testing the efficacy of biopsychosocial treatment approaches for persons having osteoarthritis and rheumatoid arthritis.

Acute and persistent pain modulation of attention-related anterior cingulate fMRI activations

&NA; The anterior cingulate cortex (ACC) has been implicated in both sustained attention (SA) and pain perception. Nonetheless, only a small body of literature has examined the relationship between SA and pain perception. This study utilized fMRI to examine activation patterns that emerged in the ACC in healthy participants and participants with chronic pain (due to osteoarthritis (OA) of the knee) while completing a sustained attention task with and without exposure to an acute painful stimulus. Independent component analysis (ICA) was used to determine groups of voxels within the ACC that covaried with performance on the SA task completed with and without exposure to a painful stimulus. In all participants, two distinct spatial patterns within the ACC were isolated that reflected (1) disrupted ACC activity when a painful stimulus was applied, or (2) emergent ACC activity when a painful stimulus was applied. In the healthy group, there were broadly distributed clusters of voxels within the ACC that were modulated by painful stimulation. But in the chronic pain group, a discrete focal region of the ACC was modulated by pain. These results demonstrate that ACC activity is modulated differently during tasks of SA and pain, and that acute pain in healthy participants and participants with chronic pain result in significantly different ACC activation patterns. Abbreviations: ACC: anterior cingulate cortex; fMRI: functional magnetic resonance imaging; IC(s): independent component(s); ICA: independent component analysis; OA: osteoarthritis; PDC: pain disrupted component; PEC: pain emergent component; PCA: principal component analysis; SA: sustained attention.

The vocational rehabilitation continuum: Maximizing outcomes through bridging the gap from hospital to community-based services

Objective: To describe and examine the effects of a specialized brain injury vocational service delivery model on vocational outcome for individuals with traumatic or other acquired brain injury. Design: A prospective case series was used. Setting: Inpatient and outpatient rehabilitation departments at a large midwest regional trauma center. Participants: Eighty adults with traumatic or other acquired brain injury were residents of the state of Minnesota, did not have a primary psychiatric or substance abuse diagnosis, and did not live in a residential care facility. Main Outcome Measures: Vocational Outcome Scale (VOS), Client Satisfaction Survey, and data on participants level of independent living, job type and setting, rate of pay, and number of hours worked per week. Results: Through emphasizing early vocational intervention, closely integrating this with medical rehabilitative treatment, and providing a smooth transition from medical to community-based services, 40% of project participants were placed in a job within the first 3 months of project participation; about 70% were placed within 12 months of project participation. Those placed have an average rate of pay of

The use of word-reading to estimate "premorbid" ability in cognitive domains other than intelligence

7.70 per hour and a 90-day job retention rate of 100%. Conclusions: Results indicate that this system of specialized brain injury vocational service delivery is effective.

Behavioral medicine: 2002 and beyond.

Diagnostic neuropsychological assessment requires the clinician to estimate a patients premorbid abilities. Word reading tests, such as the National Adult Reading Test-Revised (NART-R), provide reasonably accurate estimates of premorbid IQ, but their capacity to benchmark other premorbid cognitive abilities remains unclear. In this extension of an earlier report, we administered the NART-R, an abbreviated Wechsler Adult Intelligence Scale (WAIS-R or WAIS-III), and 26 other cognitive measures to 322 reasonably healthy adults. While NART-R performance correlated robustly (rs > or = .72) with concurrent Verbal and Full Scale IQ, its correlation with all other cognitive measures was significantly lower. Thus, while it is appealing to use word reading as a proxy for premorbid functioning in other cognitive domains, the NART-R has limited utility for this because it does not predict current performance on other cognitive tests as well as it predicts IQ in healthy adults.

New brain networks are active after right MCA stroke when moving the ipsilesional arm

This article highlights future directions for research and practice in behavioral medicine. Topics addressed include social and environmental issues, the role of technology, translational research, improving and developing interventions, and professional training and retraining.

Maximizing Vocational Outcome after Brain Injury: Integration of Medical and Vocational Hospital-Based Services

Objective: To determine whether, like the paretic arm, movement of the ipsilesional arm after middle cerebral artery (MCA) stroke is associated with widespread neural activation changes in areas anatomically and functionally connected to the lesion. Methods: In this fMRI experiment, seven patients with right MCA stroke and seven healthy control subjects performed a series of movements with their (nonparetic) right hand. Subjects either mimicked a visual display (visually guided) or generated the same motor task after a visual start signal (self-monitored). A multivariate linear discriminant analysis was used to determine the combinations of brain regions of interest (ROIs) that demonstrated maximum differences in activation between healthy and stroke subjects. The analysis was repeated within subject groups to differentiate self-monitored and visually guided movement. Results: There was a significantly different network of neural regions recruited for movement with the nonparetic, ipsilesional arm in patients with stroke vs healthy control subjects. The anterior cingulate cortex was significantly more active when patients execute self-monitored movement than visually guided movement, suggesting changes in attentional processing required for the two tasks. The lesioned hemisphere was significantly more active in patients with stroke using the nonparetic arm than in control subjects during visually guided movement. Conclusions: These results support a model of widespread bihemispheric reorganization in the motor system after a focal right hemisphere lesion. Attentional demands of self-monitored movement may be much greater than visually guided movement in patients, possibly impacting rehabilitation protocols for these patients.

Time of Day Affects Episodic Memory in Older Adults

OBJECTIVE To describe a medical and vocational case-management system that has been implemented at the Mayo Medical Center in Rochester, Minnesota, to decrease the time between onset of brain injury and successful community reintegration. DESIGN Barriers to employment are identified and targeted as part of a system that integrates medical center- and community-based services. MATERIAL AND METHODS The success of the project will be determined by several sources, including the Mayo-Portland Adaptability Inventory, a vocational rating scale, and traditional measures of vocational success (for example, level of independent living, job type and setting, rate of pay, and the type and cost of vocational supports being used). Overall study outcomes will be compared against benchmarks derived from the literature on vocational outcome after brain injury. RESULTS Preliminary data are encouraging that project goals are attainable. The medical case-management system has decreased the amount of time between injury and initiation of vocational and other rehabilitation services. During the first year, 67 persons with brain injury began receiving vocational services through the project, and 34% are in community-based nonsheltered work or training programs. Second-year data will reveal whether the goal of 70% placement within 9 months after admission to the project can be maintained.

Dementia: An Evidence-Based Review of Common Presentations and Family-Based Interventions

ABSTRACT The neuropsychological test scores of 2,030 cognitively normal older adults were examined to evaluate performance patterns as they related to time of day (TOD) at which testing was initiated. Multiple regression analyses were used to examine the association of TOD with scores on seven neuropsychological tests used in the clinical evaluation of dementia. Episodic memory performance was significantly related to TOD, while memory span and verbal fluency were not. Best performance occurred during early morning hours and late afternoon; worst performance occurred mid-day (i.e., noon). These findings may have implications for clinical assessment, the design of research on dementia, and the daily functioning of older adults.

Characteristics of Patients With Existing Advance Directives: Evaluating Motivations Around Advance Care Planning

The number of US older adults with dementia is expected to grow over the next several decades. For instance, the number of persons with Alzheimer disease is predicted to increase by 50% by 2030. Physicians commonly come into contact with patients who have dementia and, as such, need to understand its varied presentation. In the current review, the most common types of dementia, including Alzheimer disease, frontotemporal dementia, dementia due to vascular disease, and several others, are described. Characteristics and etiologic findings of cortical and subcortical dementias are differentiated, and cognitive profiles and symptoms of specific types of dementia are reviewed. An osteopathic approach to care, focusing on establishing a relationship with patients and their families, is also discussed.