Donald G. Kewman

Employment after spinal cord injury: an analysis of cases from the model spinal cord injury systems

OBJECTIVE To describe the relationship of multiple biographic, injury-related, and educational factors with employment outcomes after spinal cord injury (SCI). DESIGN Cross-sectional. SETTING Data were collected through 18 model SCI systems, a nationwide network of hospitals that treat approximately 14% of all SCIs in the United States. PARTICIPANTS A total of 3,756 persons with traumatic SCI who completed the Form II data collection during their annual follow-up at years 1, 2, 5, 10, 15, 20, or 25 years (the most recent Form II was accepted). MAIN OUTCOME MEASURES The Model Systems Forms I and II were used to identify biographic, injury-related status, employment at injury, and productivity status upon follow-up (Form I is used to elicit basic demographic and discharge information, whereas Form II is used to track multiple outcomes during annual follow-ups). The Craig Handicap Assessment Reporting Technique (CHART) was used to assess hours spent in gainful employment and other productive activities. RESULTS CHART data revealed only a modestly higher Employment rate (24.8%) than that of the traditional single Form II item (22%). Being Caucasian, younger at injury, having lived more years with SCI, having a less severe injury, and having more years of education were all predictive of being employed. Violence at injury was associated with lower employment rates (only 12.9% employed), especially among Caucasians (only 24% employed). Being employed at injury was associated with a greater probability of postinjury employment, but only in the first few years after injury. Among employed participants, women and those who had been injured fewer years averaged fewer hours spent at work. CONCLUSIONS Findings were consistent with those in previous studies. Interventions to improve employability should focus on education and the needs of individuals from minority backgrounds.

The power of nonspecific effects in healing: Implications for psychosocial and biological treatments

Abstract We evaluate the hypothesis that the power of nonspecific effects may account for as much as two thirds of successful treatment outcomes when both the healer and the patient believe in the efficacy of a treatment. Five medical and surgical treatments, once considered to be efficacious by their proponents but no longer considered effective based upon later controlled trials, were selected according to strict inclusion criteria. A search of the English literature was conducted for all studies published for each treatment area. The results of these studies were categorized, where possible, into excellent, good, and poor outcomes. For these five treatments combined, 40 % excellent, 30 % good, and 30 % poor results were reported by proponents. We conclude that, under conditions of heightened expectations, the power of nonspecific effects far exceeds that commonly reported in the literature. The implications of these results in evaluating the relative efficacy of biological and psychosocial treatments is discussed.

Cognitive Impairment in Musculoskeletal Pain Patients

To assess the incidence and relationship of cognitive/intellectual impairments to pain problems, seventy-three adults with musculoskeletal pain seen in a PM&R outpatient clinic were screened using the Neurobehavioral Cognitive Status Examination (NCSE). Subjective pain complaints were assessed using portions of the McGill Pain Questionnaire. Patients with prior diagnoses of neurocognitive problems or those who had taken narcotic analgesics in the last 24 hours were excluded. Results showed that 32 percent of subjects had impaired performance in at least one cognitive domain. Individuals with poorer performance on the NCSE had higher levels of reported pain or disability and psychological distress. Possible factors contributing to poor performance on cognitive tasks include psychological disorders or distress, undiagnosed organic brain dysfunction, social/psychological factors such as education, or a combination of these. Results suggest the need for further research to understand the relationship of poor performance on cognitive tasks to the etiology, maintenance and rehabilitation of pain problems.

Altitudinal neglect following traumatic brain injury: a case report.

We present an analysis of altitudinal neglect in a patient who following traumatic brain injury showed extinction to a visual stimulus presented in the lower field when another stimulus was simultaneously presented in the upper field. When estimating the midpoint of vertically-oriented rods presented below eye level using visual cues, tactile/kinesthetic cues or a combination of these cues, she consistently pointed higher than control subjects did. She showed less severe impairments when the rods were presented at or above eye level. When estimating the midpoint between two clicks presented above and below her head, she pointed higher than did control subjects. These deficits cannot be accounted for by sensory or motor disorders and appear to be due to a disorder in attending to stimuli in the lower half to space.

Skin Temperature Biofeedback and Migraine Headaches A Double-Blind Study ~

To assess the relative contribution of specific and nonspecific effects of skin temperature biofeedback upon migraine headache, 11 migraine patients were taught to increase the temperature of their hand. Training to decrease the skin temperature of the hand served as a control for 12 other migraine patients. An additional 11 control subjects were not trained but kept records of migraine activity. Under carefully controlled double-blind procedures, migraine patients who learned to raise finger temperatures showed statistically significant and clinically therapeutic improvement during a 6-week follow-up period. However, they were not significantly better than those trained to lower finger temperatures, those who did not meet a learning criterion, or those receiving no training. While these groups did show some significant improvement when compared to subjects who learned to decrease finger temperature, the results are most parsimoniously explained through nonspecific rather than specific factors. The necessity of using double-blind procedures in evaluating therapeutic effectiveness is again stressed.

Early development of infants with untreated metopic craniosynostosis.

Background: The purpose of this archival descriptive study was to examine the associations among craniosynostosis, perinatal risk factors or complications, and early cognitive development in infants diagnosed with craniosynostosis before they underwent surgery, to provide a greater empirical basis for surgical decision making and other early interventions. Specifically, it was hypothesized that there would be a greater number of infants with developmental delays than seen in the normative population. Furthermore, it was hypothesized that greater severity of synostosis would be correlated with lower cognitive and developmental scores. The secondary purpose of this study was to examine specific developmental domains such as language and motor skills in children with metopic craniosynostosis. Methods: The research subjects for this retrospective cross-sectional study were a consecutive series of 22 infants diagnosed with metopic synostosis: 86 percent male, ages 3.6 to 25.3 months (mean ± SD, 10.6 ± 6.4 months). Mean gestational age was 38.8 (2.3) months, mean birth weight was 107.7 ounces, and 48.1 percent subsequently had craniovault reconstruction. Severity of craniosynostosis was assessed by a plastic surgeon (Buchman) and a neurosurgeon (Muraszko) and was confirmed radiographically by an independent rater (Angobaldo). Cognitive status was assessed with the Bayley Scales of Infant Development, Second Edition, at a mean age 11.6 (4.8) months. Results: The mean Mental Development Index score for the sample was 96.0 (14.5), falling within the average range. Severity of synostosis was not significantly correlated with the overall Mental Development Index score. The mean language quotient for the sample was 77.3 (21.1). Conclusions: Despite suspicions that increased severity of deformity in infants with metopic craniosynostosis correlates with decreased cognitive and motor development, no such associations could be demonstrated. The results of this study did suggest, however, that children with isolated metopic craniosynostosis might show specific developmental delays in language acquisition. Finally, there were no significant correlations between cognitive development and prenatal risk factors.

Empirically supported psychological and behavioral therapies in pediatric rehabilitation of TBI

This article examines the empirical support for psychological therapies for children with traumatic brain injury (TBI). Empirical support for psychological treatments of noninjured children provides a foundation upon and a framework in which to discuss applications to children with neurobehavioral dysfunction. Behavioral interventions to address externalizing behaviors have received the greatest focus, whereas there is a paucity of work that pertains to internalizing features and prosocial behavior such as assertiveness. Although the systematic study of psychological intervention lags far behind the rapidly increasing knowledge of neurobehavioral sequelae to TBI, there are promising directions that stem from initial findings.

Transforming Psychological Practice and Society: Policies that Reflect the New Paradigm.

As people with disabilities challenge psychology to acknowledge the sociopolitical foundations of their marginalization, they urge psychologists to help improve disability policy within and beyond the borders of the discipline. Understanding disability through a social paradigm offers opportunities to reframe the way psychologists define problems related to disability, to develop more collaborative relationships between psychologists and people with disabilities, and to adopt new professional responsibilities with respect to the disability community. The authors address the impact of the social paradigm on policies within psychology that guide consulting, advocacy, and training. The impact of national policy decisions, such as those associated with reimbursement, on practice and training is also discussed. Highlighted throughout are points of controversy prompted by new disability frameworks that remain open to illumination from the field.

Lower extremity lawn-mower injuries in children

Lower extremity lawn-mower injuries in children result in significant morbidity with a significant financial burden to the family and society. We reviewed 24 children with lower extremity lawn-mower injuries; all mothers completed standardized psychologic assessments of their children, and 18 children were interviewed. Fifty percent of the mothers had defensive profiles on the standardized psychologic assessment, suggesting the likelihood of denial or underreporting of the childs psychologic difficulties. Therefore, we found the interview with the child to be a more accurate measure of psychologic distress. Prevention measures aimed at parents must emphasize that a child must not be allowed in a yard that is being mowed with a riding mower.

Attentional performance of children with traumatic brain injury: A quantitative and qualitative analysis of digit span

Previous studies have indicated that digit span performance is not particularly sensitive to the effects of traumatic brain injury (Baddeley & Warrington, 1970; Brooks, 1975; Sterne, 1969). However, clinical lore posits poorer backward vs. forward performance compared to normals due to the greater attentional demands of the backward task. This study examined qualitative aspects of Digit Span performance including forward/backward span discrepancies and error patterns in children with traumatic brain injury (n = 20) and normals (n = 19). The hypothesis of greater forward/backward discrepancy with traumatic brain injury was not supported. Children with traumatic brain injury make a significantly greater number of preceiling errors than normals, consistent with other findings of increased performance variability. Preceiling errors are errors that occur in trials prior to the two failed trials, resulting in discontinuation of the task. In addition, cognitive correlates of error types, such as WISC-R factor scores, were significantly different between groups. The results of this study suggest that a more detailed analysis of performance on attentional tasks previously described as resilient to brain injury may shed further light on the nature of acquired attentional deficits.