Physical Medicine and Rehabilitation Articles
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Item Inter-limb force coupling is resistant to distorted visual feedback in chronic hemiparetic stroke(Medical Journals Sweden AB, 2014) Li, Sheng; Durand-Sanchez, Ana; Latash, Mark L.; Physical Medicine and Rehabilitation, School of MedicineObjective: Interlimb coupling between impaired and non-impaired limbs after stroke has been a common observation. The aim of this study was to examine interlimb interactions in force production in responses to altered visual gain in hemiparetic stroke survivors. Design: prospective clinical study Methods: A convenient sample of 7 hemiparetic stroke subjects (3 women and 4 men; mean age 56.0 years (standard errors 12.8) of age; history of stroke: mean duration 61.6 months (standard errors 53.3)) participated in the study. Subjects performed bilateral elbow flexion to varying total force targets from 3% to 60% maximal contraction forces with normal visual gain (1:1) and to a 10% maximal voluntary contraction target with altered visual gains (1/8, 1/4, 1/2, 2, 4, and 8) for the force of the less-impaired, ipsilesional side. Results: Across all conditions, the forces produced by both impaired and non-impaired limb changed proportionally to their maximal voluntary contraction force, such that relative contributions of each limb's force to the total force remained unchanged. In conditions with altered visual gain, high and low, the total force showed errors in the direction of under-shooting. Conclusion: Our findings indicate that there is a strong interlimb force coupling in hemiparetic stroke, resistant to distorted visual feedback. It may reflect a default sharing pattern dominant after stroke.Item Diagnosing pseudobulbar affect in traumatic brain injury(Dove Press, 2014-10-07) Engelman, William; Hammond, Flora M.; Malec, James F.; Physical Medicine and Rehabilitation, School of MedicinePseudobulbar affect (PBA) is defined by episodes of involuntary crying and/or laughing as a result of brain injury or other neurological disease. Epidemiology studies show that 5.3%-48.2% of people with traumatic brain injury (TBI) may have symptoms consistent with (or suggestive of) PBA. Yet it is a difficult and often overlooked condition in individuals with TBI, and is easily confused with depression or other mood disorders. As a result, it may be undertreated and persist for longer than it should. This review presents the signs and symptoms of PBA in patients with existing TBI and outlines how to distinguish PBA from other similar conditions. It also compares and contrasts the different diagnostic criteria found in the literature and briefly mentions appropriate treatments. This review follows a composite case with respect to the clinical course and treatment for PBA and presents typical challenges posed to a provider when diagnosing PBA.Item Association Between Participation and Satisfaction With Life Over Time in Older Adults With Traumatic Brain Injury: A TBI Model Systems Study(Wolters Kluwer, 2024) Taiwo, Zinat; Sander, Angelle M.; Juengst, Shannon B.; Liu, Xiangyi; Novelo, Luis Leon; Hammond, Flora M.; O’Neil-Pirozzi, Therese M.; Perrin, Paul B.; Gut, Nicholas; Physical Medicine and Rehabilitation, School of MedicineObjective: To examine the association between participation and satisfaction with life at 1, 2, 5, and 10 years after traumatic brain injury (TBI) in older adults. Setting: Community. Participants: Participants ( N = 2362) who sustained complicated mild to severe TBI, requiring inpatient rehabilitation, at age 60 years or older and had follow-up data on participation and satisfaction with life for at least 1 follow-up time point across 1, 2, 5, and 10 years. Age at each time period was categorized as 60 to 64 years, 65 to 75 years, and 75 years or older. Design: Secondary data analysis of a large multicenter database. Main measures: Three domains (Productivity, Social Relations, Out and About) of the Participation Assessment With Recombined Tools-Objective (PART-O); Satisfaction With Life Scale (SWLS). Results: SWLS increased over the 10 years after TBI and was significantly associated with greater frequency of participation across all domains. There was a significant interaction between age and PART-O Social Relations such that there was a weaker relationship between Social Relations and SWLS in the oldest group (75 years or older). There was no interaction between Productivity or Out and About and age, but greater participation in both of these domains was associated with greater life satisfaction across age groups. Conclusions: These findings indicate that greater participation is associated with increased satisfaction with life in older adults, across all participation domains over the first 10 years postinjury, suggesting that rehabilitation should target improving participation even in older adults. The decreased association of social relations with satisfaction with life in the oldest age group suggests that frequency of social relations may not be as important for life satisfaction in the oldest adults, but quality may still be important.Item Characterizing Extreme Phenotypes for Perceived Improvement from Treatment in Persons with Chronic Pain following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Hoffman, Jeanne M.; Ketchum, Jessica M.; Agtarap, Stephanie; Dams-O’Connor, Kristen; Hammond, Flora M.; Martin, Aaron M.; Sevigny, Mitch; Walker, William C.; Harrison-Felix, Cynthia; Zafonte, Ross; Nakase-Richardson, Risa; Physical Medicine and Rehabilitation, School of MedicineObjective: To define and characterize extreme phenotypes based on perceived improvement in pain for persons with chronic pain following traumatic brain injury (TBI). Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. Primary measures: The Patient's Global Impression of Change (PGIC) related to pain treatment. Sociodemographic, injury, functional outcome, pain, and pain treatment characteristics. Results: Participants were mostly male (73%), White (75%), middle-aged (mean 46 years), injured in motor vehicle accidents (53%), or falls (20%). Extreme phenotypes were created for an extreme improvement phenotype ( n = 512, 29.8%) defined as "moderately better" or above on the PGIC and an extreme no-change group ( n = 290, 16.9%) defined as no change or worse. Least absolute shrinkage and selection operator (LASSO) regression combined with logistic regression identified multivariable predictors of improvement versus no-change extreme phenotypes. Higher odds of extreme improvement phenotype were significantly associated with being female (odds ratio [OR] = 1.85), married versus single (OR = 2.02), better motor function (OR = 1.03), lower pain intensity (OR = 0.78), and less frequent pain, especially chest pain (OR = 0.36). Several pain treatments were associated with higher odds of being in the extreme improvement versus no-change phenotypes including pain medication (OR = 1.85), physical therapy (OR = 1.51), yoga (OR = 1.61), home exercise program (OR = 1.07), and massage (OR = 1.69). Conclusion: Investigation of extreme phenotypes based on perceived improvement with pain treatment highlights the ability to identify characteristics of individuals based on pain treatment responsiveness. A better understanding of the biopsychosocial characteristics of those who respond and do not respond to pain treatments received may help inform better surveillance, monitoring, and treatment. With further research, the identification of risk factors (such as pain intensity and frequency) for treatment response/nonresponse may provide indicators to prompt changes in care for individuals with chronic pain after TBI.Item Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons with Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Nakase-Richardson, Risa; Cotner, Bridget A.; Martin, Aaron M.; Agtarap, Stephanie D.; Tweed, Amanda; Esterov, Dmitry; O’Connor, Danielle R.; Ching, Deveney; Haun, Jolie N.; Hanks, Robin A.; Bergquist, Thomas F.; Hammond, Flora M.; Zafonte, Ross D.; Hoffman, Jeanne M.; Physical Medicine and Rehabilitation, School of MedicineObjective: To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. Setting: Community. Participants: Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main measures: Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. Results: Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. Conclusion: This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.Item The Interaction of Opiate Misuse and Marijuana Use on Behavioral Health Outcomes using the Traumatic Brain Injury Model Systems Pain Collaborative Dataset(Wolters Kluwer, 2024) Callender, Librada; Lai, Tony; Driver, Simon; Ketchum, Jessica M.; Ochoa, Christa; Corrigan, John D.; Hammond, Flora M.; Harrison-Felix, Cindy; Martin, Aaron M.; Rabinowitz, Amanda R.; Starosta, Amy J.; Dubiel, Randi; Physical Medicine and Rehabilitation, School of MedicineObjective: To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes. Setting: Community. Participants: Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information. Design: Cross-sectional, secondary analysis from a multisite observational cohort. Main outcome measures: Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality. Results: Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated. Conclusions: Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association.Item Provider Perceived Facilitators and Barriers to Identifying, Perceiving, and Seeking Healthcare for Chronic Pain After TBI: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Nakase-Richardson, Risa; Cotner, Bridget A.; Agtarap, Stephanie D.; Martin, Aaron M.; Ching, Deveney; O’Connor, Danielle R.; Tweed, Amanda; Haun, Jolie N.; Hanks, Robin A.; Bergquist, Thomas F.; Hammond, Flora M.; Zafonte, Ross D.; Hoffman, Jeanne M.; Physical Medicine and Rehabilitation, School of MedicineObjective: Identify determinants to chronic pain healthcare for persons with traumatic brain injury (TBI) informed by an Access to Care Framework. Findings related to the Access Framework's core domains of identifying a need, perceptions of the need, and seeking healthcare are reported. Setting: Community. Participants: Healthcare providers (n = 63) with 2 or more years of experience treating persons with TBI interviewed between October 2020 and November 2021. Design: Descriptive, qualitative study. Main measures: Semi-structured interviews with open-ended questions of chronic pain management for persons with TBI. Informed by the Access Framework, responses were coded by and categorized within the domains of identifying healthcare needs, perceptions of needs, and factors related to healthcare seeking from the supply and demand perspective. Results: For the overall sample, 14 facilitators and 6 barriers were endorsed by more than 20% of the provider cohort. Top facilitators included on-site availability of needed resources and treatments (94%), adequate time and provider capability to ensure patient comprehension of diagnosis and treatment plans (83%), and establishing patient motivation and buy-in with the treatment plan (75%). Barriers most endorsed included policies impacting access (46%), wait times for services (41%), and patient uncertainty regarding telehealth commonly due to cognitive and physical challenges (37%). Unique determinants are reported across civilian versus Department of Veterans Affairs (VA) healthcare systems and different provider types. Conclusion: This is the first evidence-based study to inform policy and planning to improve access to high-quality chronic pain treatments for persons with TBI. Results will inform future interventions at the systems, patient, and policy levels of healthcare that can be tailored to healthcare settings (VA, Civilian) and types of providers (rehabilitation therapists, psychologists, and medical). Evidence-informed interventions may help minimize healthcare disparities experienced by persons with TBI and facilitate access to high-quality, evidence-informed chronic pain care.Item Associations of Chronic Pain With Psychosocial Outcomes After Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Hanks, Robin; Ketchum, Jessica M.; Peckham, Mackenzie; Sevigny, Mitch; Sander, Angelle M.; Martin, Aaron M.; Agtarap, Stephanie; Beaulieu, Cynthia L.; Callender, Libby; Hammond, Flora M.; Lengenfelder, Jeannie; Rabinowitz, Amanda R.; Walker, William C.; Hoffman, Jeanne M.; Harrison-Felix, Cynthia; Nakase-Richardson, Risa; Physical Medicine and Rehabilitation, School of MedicineObjective: To examine the differences in participation, life satisfaction, and psychosocial outcomes among individuals with traumatic brain injury (TBI) endorsing current, past, or no chronic pain. Setting: Community. Participants: Three thousand eight hundred four TBI Model Systems participants 1 to 30 years of age postinjury classified into 1 of 3 groups based on their pain experience: current pain, past pain, no pain completed a Pain Survey at their usual follow-up appointment which on average was approximately 8 years postinjury. Design: Multisite, cross-sectional observational cohort study. Main outcome measures: Sociodemographic and injury characteristics and psychosocial outcomes (ie, satisfaction with life, depression, anxiety, posttraumatic stress disorder [PTSD], sleep quality, community participation). Results: Persons with current chronic pain demonstrated higher scores on measures of PTSD, anxiety, and depression, and the lower scores on measures of sleep quality, community participation and satisfaction with life. Those with resolved past pain had mean scores for these outcomes that were all between the current and no chronic pain groups, but always closest to the no pain group. After adjusting for sociodemographic and function in multivariate analysis, having current chronic pain was associated with more negative psychosocial outcomes. The largest effect sizes (ES; in absolute value) were observed for the PTSD, depression, anxiety, and sleep quality measures (ES = 0.52-0.81) when comparing current pain to past or no pain, smaller ES were observed for life satisfaction (ES = 0.22-0.37) and out and about participation (ES = 0.16-0.18). When comparing past and no pain groups, adjusted ES were generally small for life satisfaction, PTSD, depression, anxiety, and sleep quality (ES = 0.10-0.23) and minimal for participation outcomes (ES = 0.02-0.06). Conclusions: Chronic pain is prevalent among individuals with TBI and is associated with poorer psychosocial outcomes, especially for PTSD, depression, anxiety, and sleep disturbance. The results from this study highlight the presence of modifiable comorbidities among those with chronic pain and TBI. Persons who experience persistent pain following TBI may be at greater risk for worse psychosocial outcomes.Item Characterizing Extreme Phenotypes for Pain Interference in Persons with Chronic Pain following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Hoffman, Jeanne M.; Ketchum, Jessica M.; Agtarap, Stephanie; Dams-O’Connor, Kristen; Hammond, Flora M.; Martin, Aaron M.; Sevigny, Mitch; Walker, William C.; Harrison-Felix, Cynthia; Zafonte, Ross; Nakase-Richardson, Risa; Physical Medicine and Rehabilitation, School of MedicineObjective: To define and characterize extreme phenotypes based on pain interference for persons with chronic pain following traumatic brain injury (TBI). Setting: Eighteen Traumatic Brain Injury Model System (TBIMS) Centers. Participants: A total of 1762 TBIMS participants 1 to 30 years post-injury reporting chronic pain at their most recent follow-up interview. Primary measures: The Brief Pain Inventory (BPI) interference scale, sociodemographic, injury, functional outcome, pain, and treatment characteristics. Results: Participants were predominantly male (73%), White (75%), middle-aged (mean 46 years), and who were injured in motor vehicle accidents (53%) or falls (20%). Extreme phenotypes were identified based on upper and lower 25th percentiles to create low-interference ( n = 441) and high-interference ( n = 431) extreme phenotypes. Bivariate comparisons found several sociodemographic, injury, function, pain, and treatment differences between extreme phenotype groups, including significant differences ( P < .001) on all measures of concurrent function with those in the low-interference extreme phenotype experiencing better function than those in the high-interference extreme phenotype. Lasso regression combined with logistic regression identified multivariable predictors of low- versus high-interference extreme phenotypes. Reductions in the odds of low- versus high-interference phenotypes were significantly associated with higher pain intensity (odds ratio [OR] = 0.33), having neuropathic pain (OR = 0.40), migraine headache (OR = 0.41), leg/feet pain (OR = 0.34), or hip pain (OR = 0.46), and more pain catastrophizing (OR = 0.81). Conclusion: Results suggest that for those who experience current chronic pain, there is high variability in the experience and impact of pain. Future research is needed to better understand how pain experience impacts individuals with chronic pain and TBI given that pain characteristics were the primary distinguishing factors between phenotypes. The use of extreme phenotypes for pain interference may be useful to better stratify samples to determine efficacy of pain treatment for individuals with TBI.Item Relationship Between Extreme Pain Phenotypes and Psychosocial Outcomes in Persons With Chronic Pain Following Traumatic Brain Injury: A NIDILRR and VA TBI Model Systems Collaborative Project(Wolters Kluwer, 2024) Ketchum, Jessica M.; Hoffman, Jeanne M.; Agtarap, Stephanie; Hammond, Flora M.; Martin, Aaron M.; Walker, William C.; Zafonte, Ross; Harrison-Felix, Cynthia; Nakase-Richardson, Risa; Physical Medicine and Rehabilitation, School of MedicineObjective: To examine the relationship between extreme pain phenotypes (interference and improvement) and psychosocial outcomes among those with chronic pain after traumatic brain injury (TBI). Setting: Community. Participants: In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain. Design: Multisite, cross-sectional, observational cohort study. Primary measures: Life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation, the Brief Pain Inventory (BPI) interference scale, and the Patient's Global Impression of Change (PGIC). Results: Persons in the extreme high interference phenotype (vs extreme low interference phenotype) and/or extreme no change phenotype (vs extreme improvement phenotype) had poorer psychosocial outcomes, with extreme pain interference phenotypes having a larger effect on outcomes than extreme perceived improvement phenotypes. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptoms (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality. Conclusions: Examination of extreme phenotypes provides important insights into the experience of individuals living with chronic pain and TBI. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI.