Anna L. Kratz

The association between symptoms, pain coping strategies, and physical activity among people with symptomatic knee and hip osteoarthritis

Effective use of coping strategies by people with chronic pain conditions is associated with better functioning and adjustment to chronic disease. Although the effects of coping on pain have been well studied, less is known about how specific coping strategies relate to actual physical activity patterns in daily life. The purpose of this study was to evaluate how different coping strategies relate to symptoms and physical activity patterns in a sample of adults with knee and hip osteoarthritis (OA; N = 44). Physical activity was assessed by wrist-worn accelerometry; coping strategy use was assessed by the Chronic Pain Coping Inventory. We hypothesized that the use of coping strategies that reflect approach behaviors (e.g., Task Persistence), would be associated with higher average levels of physical activity, whereas avoidance coping behaviors (e.g., Resting, Asking for Assistance, Guarding) and Pacing would be associated with lower average levels of physical activity. We also evaluated whether coping strategies moderated the association between momentary symptoms (pain and fatigue) and activity. We hypothesized that higher levels of approach coping would be associated with a weaker association between symptoms and activity compared to lower levels of this type of coping. Multilevel modeling was used to analyze the momentary association between coping and physical activity. We found that higher body mass index, fatigue, and the use of Guarding were significantly related to lower activity levels, whereas Asking for Assistance was significantly related to higher activity levels. Only Resting moderated the association between pain and activity. Guarding, Resting, Task Persistence, and Pacing moderated the association between fatigue and activity. This study provides an initial understanding of how people with OA cope with symptoms as they engage in daily life activities using ecological momentary assessment and objective physical activity measurement.

Sleep and Cognitive Function in Multiple Sclerosis

STUDY OBJECTIVES To examine associations between cognitive performance and polysomnographic measures of obstructive sleep apnea in patients with multiple sclerosis (MS). METHODS Participants underwent a comprehensive MS-specific cognitive testing battery (the Minimal Assessment of Cognitive Function in MS, or MACFIMS) and in-laboratory overnight PSG. RESULTS In adjusted linear regression models, the oxygen desaturation index (ODI) and minimum oxygen saturation (MinO2) were significantly associated with performance on multiple MACFIMS measures, including the Paced Auditory Serial Addition Test (PASAT; 2-sec and 3-sec versions), which assesses working memory, processing speed, and attention, and on the Brief Visuospatial Memory Test-Revised, a test of delayed visual memory. The respiratory disturbance index (RDI) was also significantly associated with PASAT-3 scores as well as the California Verbal Learning Test-II (CVLT-II) Discriminability Index, a test of verbal memory and response inhibition. Among these associations, apnea severity measures accounted for between 12% and 23% of the variance in cognitive test performance. Polysomnographic measures of sleep fragmentation (as reflected by the total arousal index) and total sleep time also showed significant associations with a component of the CVLT-II that assesses response inhibition, explaining 18% and 27% of the variance in performance. CONCLUSIONS Among patients with MS, obstructive sleep apnea and sleep disturbance are significantly associated with diminished visual memory, verbal memory, executive function (as reflected by response inhibition), attention, processing speed, and working memory. If sleep disorders degrade these cognitive functions, effective treatment could offer new opportunities to improve cognitive functioning in patients with MS. COMMENTARY A commentary on this article appears in this issue on page 1489.

Health-related quality of life in caregivers of individuals with traumatic brain injury: Development of a conceptual model

OBJECTIVES To identify aspects of health-related quality of life (HRQOL) that are relevant to caregivers of individuals with traumatic brain injury (TBI) and to propose an integrated conceptual framework based on this information. DESIGN Nine focus groups with caregivers of individuals with moderate-to-severe TBI were qualitatively analyzed to ascertain the effect that caring for an individual with a TBI has on caregiver HRQOL. SETTING University hospitals and rehabilitation treatment centers. PARTICIPANTS Caregivers (N=55) of individuals with moderate-to-severe TBI. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. RESULTS Qualitative analysis indicated that caregivers were most concerned about their social health (42% of comments). Other important issues were emotional health (34%), physical health (11%), cognitive health (3%), and feelings of loss (9%; feelings of loss related to changes in the future/potential of the care recipient or related to the caregiver). Areas of concern that were discussed that were specific to the caregiver and not fully evaluated by existing patient-reported outcomes (PROs) included feelings of loss, anxiety related to the caregiver role (reinjury concerns, worry about leaving the person alone, etc), and caregiver strain (burden, stress, feeling overwhelmed, etc). CONCLUSIONS Although existing PROs capture relevant aspects of HRQOL for caregivers, there are HRQOL domains that are not addressed. A validated and sensitive HRQOL tool for caregivers of individuals with TBI will facilitate initiatives to improve outcomes in this underserved group.

Traumatic brain injury caregivers: A qualitative analysis of spouse and parent perspectives on quality of life

The objective of this qualitative study was to examine how family caregivers of individuals with traumatic brain injury (TBI) describe their quality of life in the context of their caregiving role. Fifty-two caregivers of adults with moderate or severe TBI (n = 31 parents, n = 21 partners/spouses; 77% female; mean age = 57.96 years, range = 34–78 years) were recruited from three data collection sites to participate in focus groups. Thematic content analysis was used to identify two main meta-themes: Caregiver Role Demands and Changes in Person with TBI. Prominent sub-themes indicated that caregivers are (1) overburdened with responsibilities, (2) lack personal time and time for self-care, (3) feel that their life is interrupted or lost, (4) grieve the loss of the person with TBI, and (5) endorse anger, guilt, anxiety, and sadness. Caregivers identified a number of service needs. A number of sub-themes were perceived differently by partner versus parent caregivers. The day-to-day responsibilities of being a caregiver as well as the changes in the person with the TBI present a variety of challenges and sources of distress for caregivers. Although services that address instrumental as well as emotional needs of caregivers may benefit caregivers in general, the service needs of parent and partner caregivers may differ.

Activity pacing in daily life: A within-day analysis.

Summary Individuals with osteoarthritis reported more pacing behaviors following symptom increases (pain or fatigue) and did not reduce symptoms. Naturalistic pacing seems to be symptom‐contingent. ABSTRACT Activity pacing is a widely used self‐management strategy, but we lack a clear understanding of its nature and usefulness. One source of confusion is a lack of clarity about the use of pacing in everyday life (ie, naturalistic pacing) in people not trained on how to pace activities. It is unknown whether people engage in more pacing when pain is high (pain‐contingent) or when fatigue is high (fatigue‐contingent). Conversely, it is not known whether naturalistic pacing results in reduced symptoms. We conducted a multilevel daily process study in which participants with osteoarthritis (N = 162) reported pain and fatigue severity and frequency of pacing behaviors 5 times per day over 5 days. We hypothesized that increased pain and fatigue would predict increased pacing and that pacing would have a short‐term benefit in terms of decreased pain and fatigue. Multilevel modeling results showed that, as expected, both momentary pain and fatigue were positively associated with subsequent pacing behaviors. Contrary to our hypothesis, increased pacing was associated with higher subsequent levels of pain and fatigue. Naturalistic pacing seems symptom‐contingent and not reinforced by symptom reduction. Naturalistic pacing may be distinct from trained or programmatic pacing in terms of outcomes, and further research into naturalistic pacing may provide an important foundation for how best to deliver activity pacing interventions.

Women's experiences of living with neurogenic bladder and bowel after spinal cord injury: life controlled by bladder and bowel

Abstract Purpose: Neurogenic bladder and bowel (NBB) is a chronic condition hindering the functioning and quality of life (QOL) of people with spinal cord injury (SCI). NBB research has focused on men with SCI leaving unanswered questions about womens experiences of living with NBB. The purpose of this study was to identify and describe womens experiences of living with SCI and NBB. Method: Secondary analysis of semi-structured interviews from a larger qualitative study of women with SCI (N = 50) was carried out. Transcripts were coded for bowel and bladder content. Pile-sorting techniques were used to identify emergent themes related to NBB. Meta-themes were categorized under the International Classification of Functioning, Disability and Health. Results: Bladder and bowel topics were spontaneously discussed by 46 out of 50 study participants suggesting the salience of this issue for women with SCI. We identified 6 meta-themes: life controlled by bladder and bowel, bladder and bowel accidents, womens specific challenges, life course disruption, bladder and bowel medical management, and finding independence. Conclusions: Findings describe concerns, strategies, and the detrimental impact of NBB in the lives of women with SCI. Findings inform policy makers, health care and rehabilitation professionals to improve accessibility and quality of life for women with NBB. Implications for Rehabilitation Women with spinal cord injury (SCI) reported gender specific challenges to living with neurogenic bladder and bowel (NBB). Interventions designed for women with SCI can address these problems and provide recommendations for prevention and treatment. Women described the detrimental impact of NBB on life course expectations, emotional, social, physical health, and quality of life domains. Psychosocial and educational programs can be developed to address these challenges and improve overall quality of life. Recommendations for special treatment and policy considerations are needed to maximize womens independence and health while living with NBB after SCI.

Effects of cognitive task demands on subsequent symptoms and activity in adults with symptomatic osteoarthritis.

OBJECTIVE Adults with osteoarthritis (OA) experience fatigue in daily life that is negatively related to physical activity; however, it is unclear how task demands affect fatigue and occupational performance. We examined effects of a cognitive task on subsequent symptoms and activity. METHOD Adults with knee or hip OA completed a standardized cognitive task during a lab visit. Objective physical activity and symptoms were tracked during two home-monitoring periods (i.e., 4-day period before and 5-day period after the lab visit). Multilevel modeling was used to compare pretask with posttask fatigue, pain, and activity levels. RESULTS Fatigue increased and pain decreased for 2 days after performing the lab task. The authors found no pretask to posttask changes in activity levels. At posttask, daily fatigue and activity patterns changed relative to baseline. CONCLUSION For adults with symptomatic OA, cognitive task demands may be an important contributor to fatigue and pain.

Caring for our wounded warriors: A qualitative examination of health-related quality of life in caregivers of individuals with military-related traumatic brain injury

The purpose of this study was to develop a conceptual framework that captures aspects of health-related quality of life (HRQOL) for caregivers of individuals with military-related traumatic brain injury (TBI). We analyzed qualitative data from nine focus groups composed of caregivers of wounded warriors with a medically documented TBI. Focus group participants were recruited through hospital-based and/or community outreach efforts at the Walter Reed National Military Medical Center, the University of Michigan, and Hearts of Valor support groups (Tennessee and Washington). Participants were the caregivers (n = 45) of wounded warriors who had sustained a mild, moderate, severe, or penetrating TBI. Qualitative frequency analysis indicated that caregivers most frequently discussed social health (44% of comments), followed by emotional (40%) and physical health (12%). Areas of discussion that were specific to this population included anger regarding barriers to health services (for caregivers and servicemembers), emotional suppression (putting on a brave face for others even when things are not going well), and hypervigilance (controlling ones behavior/environment to prevent upsetting the servicemember). Caring for wounded warriors with TBI is a complex experience that positively and negatively affects HRQOL. While some aspects of HRQOL can be evaluated with existing measures, evaluation tools for other important components do not exist. The development of military-specific measures would help facilitate better care for these individuals.

Characterizing Pain Flares From the Perspective of Individuals With Symptomatic Knee Osteoarthritis.

Although pain in knee osteoarthritis (OA) commonly affects activity engagement, the daily pain experience has not been fully characterized. Specifically, the nature and impact of pain flares is not well understood. This study characterized pain flares as defined by participants with knee OA. Pain flare occurrence and experience were measured over 7 days.

Ecological Momentary Assessment of Pain, Fatigue, Depressive, and Cognitive Symptoms Reveals Significant Daily Variability in Multiple Sclerosis

OBJECTIVE To describe the daily variability and patterns of pain, fatigue, depressed mood, and cognitive function in persons with multiple sclerosis (MS). DESIGN Repeated-measures observational study of 7 consecutive days of home monitoring, including ecological momentary assessment (EMA) of symptoms. Multilevel mixed models were used to analyze data. SETTING General community. PARTICIPANTS Ambulatory adults (N=107) with MS recruited through the University of Michigan and surrounding community. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE EMA measures of pain, fatigue, depressed mood, and cognitive function rated on a 0 to 10 scale, collected 5 times a day for 7 days. RESULTS Cognitive function and depressed mood exhibited more stable within-person patterns than pain and fatigue, which varied considerably within person. All symptoms increased in intensity across the day (all P<.02), with fatigue showing the most substantial increase. Notably, this diurnal increase varied by sex and age; women showed a continuous increase from wake to bedtime, whereas fatigue plateaued after 7 pm for men (wake-bed B=1.04, P=.004). For the oldest subgroup, diurnal increases were concentrated to the middle of the day compared with younger subgroups, which showed an earlier onset of fatigue increase and sustained increases until bed time (wake-3 pm B=.04, P=.01; wake-7 pm B=.03, P=.02). Diurnal patterns of cognitive function varied by education; those with advanced college degrees showed a more stable pattern across the day, with significant differences compared with those with bachelor-level degrees in the evening (wake-7 pm B=-.47, P=.02; wake-bed B=-.45, P=.04). CONCLUSIONS Findings suggest that chronic symptoms in MS are not static, even over a short time frame; rather, symptoms-fatigue and pain in particular-vary dynamically across and within days. Incorporation of EMA methods should be considered in the assessment of these chronic MS symptoms to enhance assessment and treatment strategies.