Kristofer J. Hagglund

A meta-analysis of fibromyalgia treatment interventions.

Objective: To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS). Methods: This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures—physical status, self-report of FMS symptoms, psychological status, and daily functioning. Results: After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures. Conclusion: The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Medical rehabilitation length of stay and outcomes for persons with traumatic spinal cord injury—1990–1997

OBJECTIVES To describe changes in acute and rehabilitation length of stay (LOS) for persons with traumatic spinal cord injury (SCI), describe predictors of LOS, and explore year-1 anniversary medical and social outcomes. DESIGN Longitudinal, exploratory study of patients with SCI. SETTING Eighteen Model Spinal Cord Injury Centers across the United States. SAMPLE A total of 3,904 persons discharged from the Model Systems between 1990 and 1997 who had follow-up interviews at 1 year postinjury. MAIN OUTCOME MEASURES Rehabilitation LOS; injury anniversary year-1 presence of pressure ulcers; incidence of rehospitalization; community or institutional residence; and days per week out of residence. RESULTS Acute rehabilitation LOS declined from 74 days to 60 days. Discharges to nursing homes and rehospitalizations increased between 1990 and 1997. Linear regression showed that lower admission motor Functional Independence Measure (FIM) scores, year of discharge from the Model System, method of bladder management, tetraplegia, race, education, marital status, discharge disposition, and age were related to longer LOS. At first anniversary, logistic regressions revealed that lower discharge motor FIM, injury level, and age were related to the presence of pressure ulcers, rehospitalization, residence, and time spent out of residence. Of those discharged to nursing homes, 44% returned to home by year 1, and these individuals had higher functional status and were younger. DISCUSSION High functional status is associated with shorter LOS, discharge to the community, and time spent out of residence, indicating efficiency in the system. For 44.4% of individuals one or more of the following outcomes were observed by first year anniversary: rehospitalization; residing in a skilled nursing facility; having pressure ulcers; or infrequently leaving ones residence.

Access to health care services among people with chronic or disabling conditions: patterns and predictors.

OBJECTIVE To examine patterns of access to a variety of specific health care services among people with chronic or disabling conditions, focusing on factors that predict access to services. DESIGN National survey of 800 adults with cerebral palsy (CP), multiple sclerosis (MS), spinal cord injury (SCI), or arthritis. SETTING Respondents were surveyed in the general community. PARTICIPANTS National convenience sample of adults with CP, MS, SCI, or arthritis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Access to services from primary care doctors, services from specialists, rehabilitative services, assistive equipment, and prescription medications. Cross tabulations and logistic regression analyses were performed on survey data to examine patterns and predictors of access to health care services. RESULTS Only half of all respondents received needed rehabilitative services. Respondents covered by fee-for-service health plans were more likely than those covered by managed care organizations to receive needed services from specialists. Respondents with the poorest health and with the lowest incomes were the least likely to receive all health services examined. CONCLUSIONS People with chronic or disabling conditions often require a comprehensive array of health care services. Reform of the current health care payment and delivery structures is needed so that health care is more responsive to those with the greatest service needs.

Removing service barriers for women with physical disabilities: promoting accessibility in the gynecologic care setting

Although women with disabilities constitute a substantial segment of the population, their gynecologic health care needs often go unrecognized or untreated. Women with disabilities encounter a variety of obstacles to receiving health services including attitudinal, environmental, economic, and informational barriers. Standard screening and preventive services, such as pelvic examinations and mammograms, can be especially difficult to obtain, potentially placing women with disabilities at greater risk for diseases such as breast cancer and cervical cancer. This article reviews the current status of gynecologic care for women with disabilities and provides strategies for womens health care providers seeking to increase the accessibility of their practice settings.

Trajectories of adaptation in pediatric chronic illness : The importance of the individual

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Access to healthcare services among persons with osteoarthritis and rheumatoid arthritis

Hagglund KJ, Clark MJ, Hilton SA, Hewett JE: Access to healthcare services among persons with osteoarthritis and rheumatoid arthritis. Am J Phys Med Rehabil 2005;84:702–711. Objective: Persons with osteoarthritis and rheumatoid arthritis frequently require access to a broad range of healthcare services. The purpose of the current study was to examine the healthcare access experiences of these two populations. Design: Mail surveys were completed by 409 adults with self-reported osteoarthritis or rheumatoid arthritis who were recruited through a variety of recruitment strategies such as advertisements placed in arthritis publications, internet sources, and physician referrals. Results: Participants self-reported not obtaining needed health care at high rates for several service domains, including mental health services (42%) and rehabilitation therapies (39%). The most frequent reasons for not obtaining services included lack of service coverage by the health plan and high costs. Type of arthritis was predictive of the ability to obtain primary doctor services. Conclusions: The United States healthcare system continues to focus on treating acute disorders and has yet to adapt to the growing prevalence of chronic illness and disability. Changes will be needed in both healthcare financing and delivery structures to promote access to specialized services such as mental health services and rehabilitation therapies for persons with osteoarthritis and rheumatoid arthritis.

Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation.

Schopp LH, Clark M, Mazurek MO, Hagglund KJ, Acuff ME, Sherman AK, Childers MK: Testosterone levels among men with spinal cord injury admitted to inpatient rehabilitation. Am J Phys Med Rehabil 2006;85:678–684. Objective:Although previous research has shown an association between spinal cord injury (SCI) and testosterone production, these studies have yielded inconsistent results. The present study documented the prevalence of low testosterone among men with SCI. Design:Participants were 92 men with SCI participating in inpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, neurologic level and degree of incomplete function, American Spinal Injury Association Impairment Scale grade, and additional laboratory values, including prealbumin, albumin, hematocrit, and aspartate aminotransferase. Results:The median testosterone level for men who sustained injuries <4 mos earlier was 160 ng/dl. Testosterone categories were significantly associated with age, time since injury, hematocrit, albumin level, and aspartate aminotransferase in the univariate analyses. Age, time since injury, and hematocrit levels were significant predictors of low testosterone in the multivariate analysis. Conclusion:The prevalence of low testosterone among men with acute SCI seems to be high. The results suggest the need for routine screening for low testosterone among men with SCI and consideration given to testosterone replacement therapy. Future research is needed to investigate the etiology, pathogenesis, and potential avenues for treatment of low testosterone among men with SCI.

A comparison of consumer-directed and agency-directed personal assistance services programmes

Purpose: To compare a consumer-directed personal assistance services (PAS) programme with an agency-directed PAS programme. Method: A convenience sample was used for this cross-sectional study with one data collection point. Outcomes were compared for consumer-directed and agency-directed PAS. Hierarchical regressions were also used to determine the predictors of outcomes across PAS programmes. In-home interviews were conducted by a trained data collector from April 2000 to December 2001. Results: Participants in the consumer-directed programme reported more choices over PAS and satisfaction with PAS. Self-reported outcomes were primarily predicted by the following variables: service arrangement, type of provider, importance of directing PAS, health status, number of personal assistants used in past 12 months, sufficient PAS hours received, and social support. Conclusions: Consumer-directed PAS enhances outcomes for many persons with disabilities. Self-reported outcomes are affected by many factors that could be addressed in PAS programme development.

Occupational Burnout, Tolerance for Stress, and Coping Among Nurses in Rehabilitation Units

Timothy R. ElliottRichard ShewchukUniversity of Alabama at BirminghamKristofer HagglundUniversity of Missouri-ColumbiaBruce RybarczykRush-Presbyterian-St. Lukes Medical Center Chicago, ILStephen HarkinsMedical College of Virginia/Virginia Commonwealth UniversityABSTRACT. The relation of problem-solving confidence, perceived tolerance,and situation-specific coping efforts to occupational burnout was examinedamong nurses in physical rehabilitation units. Consistent with predictions,confidence in ones ability to handle problems and perceived tolerance weresignificantly predictive of lower burnout scores, regardless of time spent on thejob. Of the coping variables, emotion-focused coping was significantly associ-ated with higher burnout scores. Post-hoc inspection of self-reported copingactivities generated in response to a thought-listing probe indicated that somecoping efforts (e.g., taking time off from work, confronting a supervisor) couldbe construed as symptoms of burnout, according to theoretical conceptualizations.Implications for contemporary notions of burnout and psychosocial interven-tions with rehabilitation staff are discussed.Occupational burnout is considered endemic to the human service professions,and the construct has achieved considerable — albeit uncritical — acceptancein the popular culture and contemporary workplace. People in the humanservice professions are particularly at risk for burnout as their work isemotionally involving, and work outcomes can be relatively independent o f theeffort exerted by the professional (Maslach & Jackson, 1982; Pines & Aronson,1989). Occupational burnout is associated with increased work experience

Disability and satisfaction with access to health care

Data that estimate international prevalence of disability are sparse. In the United States, estimates of the prevalence of persons with disability range from 3% to 20% of the population.1Although some national level data are collected on disability, surveillance data are not collected routinely by most American state health departments. The purpose of this study was to examine the association between disability and access to health care using existing surveillance data. Ultimately, understanding these associations should assist public health officials to implement more effective, accessible, and acceptable public health intervention programmes to persons with disability. Three special area random digit dialled telephone surveys were conducted in Missouri State from 1995 through 1997. Surveys and subject selection were based on the methods of the Behavioral Risk Factor Surveillance System (BRFSS), a health survey supported by the Centers for Disease Control and Prevention (CDC). Our outcome variable was disability status, based on a standard BRFSS question “are you limited in any way, in any activity, because of any impairment or health problem?” This question has been found to be reliable in disability …