Richard L. Wanlass

Employment profiles in neuromuscular diseases

Consumer and rehabilitation provider factors that might limit employment opportunities for 154 individuals with six slowly progressive neuromuscular diseases (NMD) were investigated. The NMDs were spinal muscular atrophy (SMA), hereditary motor sensory neuropathy (HMSN), Beckers muscular dystrophy (BMD), facioscapulohumeral muscular dystrophy (FSHD), myotonic muscular dystrophy (MMD), and limb-girdle syndrome (LGS). Forty percent were employed in the competitive labor market at the time of the study, 50% had been employed in the past, and 10% had never been employed. The major consumer barrier to employment was education. Other important factors were type of occupation, intellectual capacity, psychosocial adjustment, and the belief by most individuals that their physical disability was the only or major barrier to obtaining a job. Psychological characteristics were associated with level of unemployment. However, physical impairment and disability were not associated with level of unemployment. There also were differences among the types of NMDs. Compared with the SMA, HMSN, BMD, and FSHD groups, the MMD and LGS groups had significantly higher levels of unemployment, lower educational levels, and fewer employed professional, management, and technical workers. Nonphysical impairment factors such as a low percentage of college graduates, impaired intellectual function in some individuals, and poor psychological adjustment were correlated with higher unemployment levels in the MMD group. Unemployment in the LGS group was correlated with a failure to complete high school. Major provider barriers to employment were the low level of referrals to Department of Rehabilitation by physicians and the low percentage of acceptance into the State Department of Rehabilitation. The low rate of acceptance was primarily attributable to the low number of referrals compounded by a lack of counselor experience with individuals with NMD. Both consumer and provider barriers may contribute to the lack of interest in obtaining a job.

A profile of psychosexual functioning in males following spinal cord injury

The psychosexual functioning of 47 men with spinal cord injury was studied using the Derogatis Sexual Functioning Inventory (DSFI). Subjects with paraplegia did not differ significantly from subjects with quadriplegia on any of the scales of the DSFI. Subject groups were then aggregated, and the means across DSFI scales were compared to the means of the non-disabled DSFI normative group. This comparison revealed significantly below-normal scores for subjects with spinal cord injury on the Body Image, Gender Role Definition, Experience, and Psychological Symptoms scales, as well as on a composite measure of sexual functioning, the Sexual Functioning Index. The meaning of these results is discussed, and implications for intervention are considered.

The Symbol Trail Making Test: Test Development and Utility as a Measure of Cognitive Impairment

Although the Trail Making Test (TMT) has proven to be an exceptional clinical tool, its applications have been limited by the instruments use of the Arabic numeral system and Latin alphabet. Clearly an instrument not limited by a specific alphabet or numerical system could fill this void. This study presents the development and validation of an alternative to the TMT that offers modestly similar psychometric properties and can be used with populations that have no familiarity with the Arabic numerical system or a specific alphabet. The Symbol Trail Making Test (STMT), which employs symbols that are not language or numerically based was administered to a normative sample of 210 participants, including 54 individuals whose first language was not English, for the purpose of collecting normative data. Reliability, assessed through an alternate form administration, and convergent validity, assessed through correlation with the TMT in a nonpatient sample, was deemed acceptable. Significant discriminant validity was obtained comparing non-brain-injured patients to brain-injured patients, particularly on time measures. An analysis of variance found no significant difference between native English speakers and individuals speaking English as a second language on performance on the STMT. This preliminary study provides evidence that the STMT is a clinically useful instrument for discriminating brain-injured from non-brain-injured participants without employing a specific culture-bound symbol system.

Interacting with Others

Rule I-A01: Make sure you know who the real referral source is, as sometimes a primary care physician is required by an insurance company to formally make the referral, whereas the professional actually wanting to see the results is a specialist such as a psychiatrist, physiatrist, or neurologist.

Profiles of functional recovery in fifty traumatically brain-injured patients after acute rehabilitation

Research to demonstrate the efficacy of head injury rehabilitation is important at a time when cost-containment efforts are intensifying. A useful tool that would predict the functional improvement during hospitalization and length of stay (LOS) of persons with traumatic brain injury would be of benefit to patients and their families, insurance carriers, and rehabilitation specialists. This study examines functional improvements made by 50 traumatic brain-injured patients admitted to the rehabilitation unit at the University of California, Davis, Medical Center (UCDMC) as measured by the UCDMC Davis Functional Status Measure (DFSM), which was adapted from the Functional Independence Measure (FIM). The DFSM incorporates additional items to provide a more thorough measure of skills to be rehabilitated. The purpose of this study was to compare scores and profiles on the DFSM items obtained by patients with LOS greater than and less than and equal to the median rehabilitation LOS (23 days). Relationships were explored among admission DFSM scores, LOS for rehabilitation, discharge destination, and functional outcome. Results indicate that patients admitted to the rehabilitation unit attained a similar profile or level of function by discharge, regardless of admission Glasgow Coma Scale scores or admission DFSM scores. There were no significant differences in admission Glasgow Coma Scale score, age, acute LOS, or discharge disposition between the LOS groups. There was a significant difference in median admission DFSM score in 26 of 31 categories between the LOS groups. There was a significant difference in median DFSM change (admission to discharge) in 24 of 31 categories between the LOS groups. The admission DFSM total score was inversely proportional to the length of stay, with a correlation coefficient of 0.78. DFSM change and admission to discharge was linearly correlated with LOS (R = 0.66). The DFSM documents functional outcome and measures gains during inpatient rehabilitation. The DFSM profile is helpful in predicting the LOS needed to achieve those gains.

Interdisciplinary assessment strategies for capturing the elusive executive.

Schutz LE, Wanlass RL: Interdisciplinary assessment strategies for capturing the elusive executive. Am J Phys Med Rehabil 2009;88:419–422. Executive theory states that the executive functions are activated selectively based on the subjective perception that the immediate task is too difficult to handle through behavioral habits and too important to risk failure. Consequently, tests intended to assess the executive functions can serve their intended purpose only when they are so perceived. Because individual differences in motivation and attitudes are extensive, no single test can be presumed to measure executive function for all subjects. Executive assessment should use a variety of diverse measurement procedures to define a range of functioning. The transdisciplinary team possesses powerful advantages in conducting a diversified assessment of this kind.

Self-Report Questionnaire

Most of this questionnaire is self-explanatory, but there are two pages that require some explanation.

Rehabilitation Professionals Still Do Not Communicate Effectively About Cognition

OBJECTIVE To examine current use of descriptive labels for levels of cognitive impairment and types of memory to explore whether rehabilitation disciplines are now communicating more effectively. DESIGN Survey of rehabilitation professionals. SETTING Hospital rehabilitation programs. PARTICIPANTS Respondents (N=130) representing 8 facilities in 5 states completed surveys. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Responses to survey questions about severity and types of memory impairment were examined with the Kruskal-Wallis test to determine the impact of profession on ratings. Post hoc Mann-Whitney U test comparisons of the 2 professions with the most cognitive assessment experience, psychologists/neuropsychologists and speech-language pathologists, were conducted. RESULTS Ratings of various deficit levels differed significantly by profession (mild: H=39.780, P<.000; moderate: H=43.309, P<.000; severe: H=38.354, P<.000), but not by program location. In comparing psychologists/neuropsychologists and speech-language pathologists specifically, we found a significant discrepancy in ratings for percentile ranges associated with the terms mild (U=103.000, P<.001), moderate (U=78.000, P<.000), and severe (U=109.000, P<.001). Disagreement on the meaning of descriptive memory terms was noted among rehabilitation professionals in general, with large percentages of respondents not agreeing on the meanings of terms. CONCLUSIONS A significant lack of consensus persists regarding the understanding of common cognitive terminology. This miscommunication affects cognitive impairment descriptors (eg, mild, moderate, severe) and categorization of types of memory. Only half of rehabilitation professionals appear aware of this discrepancy, suggesting that education is necessary to bring greater awareness of the potential for miscommunication.

Long Report Format

This report format is more suited for medical-legal contexts such as workers’ compensation, disability insurance, and personal injury. It prompts the writer to provide more extensive background information and provides for the reader a more comprehensive explanation of what has been assessed and why.

Family Report Questionnaire

This is a re-worded version of the self-report questionnaire for use in cases in which the patient lacks either the time or the ability to provide background information in writing. When corroboration or extra detail is important, this questionnaire may also be used to gather supplemental information even in cases in which the patient does complete the self-report version.