Percival H. Pangilinan

The contributions of self-reported injury characteristics and psychiatric symptoms to cognitive functioning in OEF/OIF veterans with mild traumatic brain injury.

Mild traumatic brain injury (mTBI) affects a significant number of combat veterans returning from Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Although resolution of mTBI symptoms is expected over time, some individuals continue to report lingering cognitive difficulties. This study examined the contributions of self-reported mTBI injury characteristics (e.g., loss of consciousness, post-traumatic amnesia) and psychiatric symptoms to both subjective and objective cognitive functioning in a sample of 167 OEF/OIF veterans seen in a TBI clinic. Injury characteristics were not associated with performance on neuropsychological tests but were variably related to subjective ratings of cognitive functioning. Psychiatric symptoms were highly prevalent and fully mediated most of the relationships between injury characteristics and cognitive ratings. This indicates that mTBI characteristics such as longer time since injury and loss of consciousness or post-traumatic amnesia can lead to increased perceived cognitive deficits despite having no objective effects on cognitive performance. Psychiatric symptoms were associated with both cognitive ratings and neuropsychological performance, illustrating the important role that psychiatric treatment can potentially play in optimizing functioning. Finally, subjective cognitive ratings were not predictive of neuropsychological performance once psychiatric functioning was statistically controlled, suggesting that neuropsychological assessment provides valuable information that cannot be gleaned from self-report alone.

WAIS-IV Reliable Digit Span is no More Accurate Than Age Corrected Scaled Score as an Indicator of Invalid Performance in a Veteran Sample Undergoing Evaluation for mTBI

Reliable Digit Span (RDS) is a measure of effort derived from the Digit Span subtest of the Wechsler intelligence scales. Some authors have suggested that the age-corrected scaled score provides a more accurate measure of effort than RDS. This study examined the relative diagnostic accuracy of the traditional RDS, an extended RDS including the new Sequencing task from the Wechsler Adult Intelligence Scale-IV, and the age-corrected scaled score, relative to performance validity as determined by the Test of Memory Malingering. Data were collected from 138 Veterans seen in a traumatic brain injury clinic. The traditional RDS (⩽ 7), revised RDS (⩽ 11), and Digit Span age-corrected scaled score (⩽ 6) had respective sensitivities of 39%, 39%, and 33%, and respective specificities of 82%, 89%, and 91%. Of these indices, revised RDS and the Digit Span age-corrected scaled score provide the most accurate measure of performance validity among the three measures.

Disability attitudes in health care: a new scale instrument.

Objective: The aims of this study were to develop and validate an instrument measuring attitudes toward providing health care to patients with disability, to compare the attitudes of preclinical and clinical medical students, and to examine whether sex, a background in disability, or career interest in physical medicine and rehabilitation affect medical student attitudes toward working with patients with disability. Design: A cross-sectional survey was conducted in an academic medical center with participants that included preclinical (n = 63) and clinical medical (n = 58) students, physical medicine and rehabilitation residents (n = 18), and internal medicine residents (n = 10). A 17-item Disability Attitudes in Health Care scale was developed based on existing, validated geriatrics attitudes scales. Attitudes Toward Disabled Persons Form O scale was used for correlation testing. Background demographic data collected from medical student respondents included sex, previous personal or work experience with disability, and career interest in physical medicine and rehabilitation. Results: The new scale demonstrated high reliability (Cronbach &agr; = 0.74) and criterion validity (correlation coefficient = 0.54 with the Attitude Towards Disabled Persons scale). Attitudes were no different between preclinical and clinical medical students. Male medical students had more negative attitudes than female students did (P = 0.03). Students with a higher level of career interest in physical medicine and rehabilitation scored higher than less interested students did (P = 0.015). Conclusions: The new Disability Attitudes in Health Care scale developed in this study shows good internal consistency and criterion validity. Attitudes toward caring for patients with disability seem to be unrelated to the standard medical education curriculum or previous experience with disability. Specific educational experiences may be designed to engender more positive attitudes toward providing health care to this patient population.

Ultrasound evaluation of a spontaneous plantar fascia rupture.

Louwers MJ, Sabb B, Pangilinan PH: Ultrasound evaluation of a spontaneous plantar fascia rupture. Plantar fascia rupture is an occasional complication in patients with chronic plantar fasciitis or in patients with plantar fasciitis treated with steroid injection. Very few cases of spontaneous plantar fascia rupture have been reported in the literature (Herrick and Herrick, Am J Sports Med 1983;11:95; Lun et al, Clin J Sports Med 1999;9:48–9; Rolf et al, J Foot Ankle Surg 1997;36:112–4; Saxena and Fullem, Am J Sports Med 2004;32:662–5). Spontaneous medial plantar fascia rupture in a 37-yr-old man with no preceding symptoms or steroid injections was confirmed with diagnostic ultrasound, which revealed severe fasciitis at the calcaneal insertion with partial tearing. After conservative treatment, the patient returned to full activities. We discuss the anatomy, risk factors, examination findings, and treatment for this condition, as well as the unique benefits that ultrasound offers over magnetic resonance imaging. It is important to consider plantar fascia rupture in patients with hindfoot pain and medioplantar ecchymosis, particularly if an injury occurred during acceleration maneuvers. Ultrasound in these cases can be used to diagnose a plantar fascia tear quickly, accurately, and cost-effectively.

Limited usefulness of the Rey Fifteen-Item Test in detection of invalid performance in veterans suspected of mild traumatic brain injury

Abstract Objective: This study explored using the FIT as a measure of performance validity among veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). Background: The Rey Fifteen-Item Memory Test (FIT) is a performance validity measure criticized for poor sensitivity. Methods: Two hundred and fifty-seven veterans completed the FIT and Wechsler Adult Intelligence Scale, Fourth Edition, Digit Span (DS); 109 of whom completed the Test of Memory Malingering (TOMM). FIT cut-offs of <9, <8 and stricter cut-offs were examined using DS and/or TOMM as criterion performance validity measures. Results: Only four participants scored below the standard cut score of 9 on the FIT. Among the 13 veterans failing both criterion tests, only two scored below 9 on the FIT. Regardless of which FIT cut-off was used, the FIT had poor diagnostic accuracy. Conclusion: Despite its popularity, the FIT is not supported as an appropriate measure of performance validity in veterans undergoing evaluation for possible mTBI. Therefore, inferences regarding neuropsychological data reliability with adequate statistical certainty require use of other measures of performance validity with greater sensitivity.

Neuropsychological test validity in Veterans presenting with subjective complaints of ‘very severe’ cognitive symptoms following mild traumatic brain injury

Abstract Objective: This study explored the utility of combining data from measures of performance validity and symptom validity among Veterans undergoing neuropsychological evaluation for mild traumatic brain injury (mTBI). Background: Persistent cognitive impairments following mTBI are often reported by returning combat veterans. However, objectively-measured cognitive deficits are not common among individuals with mTBI, raising the question of whether negative impression management influences self-ratings. Methods: Self-report ratings were obtained for memory, concentration, decision-making, and processing speed/organization using a 5-point scale ranging from ‘none’ to ‘very severe’. Veterans also completed brief neuropsychological testing which included measures of performance validity. Results: Study 1 examined data from 122 participants and demonstrated that veterans reporting a ‘very severe’ cognitive deficit were over three times as likely to demonstrate poor effort on a validity test than those without a very severe rating. Study 2 replicated these findings in an independent sample of 127 veterans and also demonstrated that both severity of self-report ratings and performance on an embedded measure of effort were predictive of poor effort on a stand-alone performance validity test. Conclusion: Veterans with suspected mTBI who report ‘very severe’ cognitive impairment have a greater likelihood of putting forth sub-optimal effort on objective testing.

Affect and psychiatric symptoms in a veteran polytrauma clinic

Although the relationship between negative affect and psychiatric symptoms has been well-demonstrated in research, less is known about positive affect relative to negative affect, and its relationship to psychiatric symptoms, especially among veterans. This study examined how levels of positive and negative affect are associated with symptoms of depression, anxiety, and posttraumatic stress disorder (PTSD). Data were collected in a veteran polytrauma clinic; analyses were conducted using data from 94 veterans (87 males) with and without a mild traumatic brain injury (mTBI) diagnosis. Results demonstrate that positive and negative affect were separate dimensions and that both were independently related to each symptom measure. After removing the contribution of negative affect from symptom reports, strong relationships remained between positive affect and psychiatric symptoms. Furthermore, the magnitude of the associations for positive affect and for negative affect with symptoms of depression, anxiety, and PTSD were not impacted by a mTBI diagnosis. Altogether, findings suggest that both positive and negative affect should be uniquely considered when conceptualizing, assessing, and treating returning service members; in addition, positive affect may be an appropriate target of assessment and interventions of persons who have experienced polytrauma.

Reliability and factor structure of the hospital anxiety and depression scale in a polytrauma clinic

The Hospital Anxiety and Depression Scale (HADS) is a brief self-report measure of anxiety and depression symptoms. This study examined the internal consistency and factor structure of the HADS among Veterans in a polytrauma/traumatic brain injury clinic. The sample consisted of 312 Veterans. A confirmatory factor analysis of the depression and anxiety subscales showed, not surprisingly, that the two factors were highly correlated (r = 0.7). Goodness of fit statistics for the two-factor model were acceptable (root mean square error of approximation = 0.06, comparative fit index = 0.94). The HADS demonstrated very good reliability overall (alpha = 0.89) and for the individual subscales (alpha = 0.84). This study supports the use of the HADS as a screen for depression and anxiety in the assessment of mild traumatic brain injury in a Veteran population.

Rehabilitation of the muscular dystrophies.

The muscular dystrophies (MD) are a heterogeneous group of inherited disorders characterized by findings on muscle biopsy. In general, they feature progressive muscle wasting and weakness. In addition to the musculoskeletal system, direct and indirect effects can be seen in a variety of organ systems. These issues create challenges in patients with MD for ambulation and mobility, self-care, pain, fatigue, and community involvement. Because of its progressive nature and wide variety of pathophysiological mechanisms, patients with MD require individualized rehabilitation care. This chapter reviews specific rehabilitation needs and treatment of patients with MD.

Controversial topic: Return to competitive sport after severe traumatic brain injury

Various guidelines have been proposed for returning to sport after concussion or mild TBI. However, no such guidelines exist for severe TBI. This study presents three cases of athletes who sustained severe TBIs and returned to competition. The rational for their clearance will be discussed.