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Objective: Informed by Minority Stress Theory, to investigate disparities in pain intensity, interference, and care in patients with spinal cord injuries (SCI) based on demographic features., Design: Cross-sectional survey., Setting: Outpatient SCI clinics in 2 academic medical centers in the northwestern United States., Participants: Sample of 242 SCI clinic patients who endorsed SCI-related pain, were ≥18-years-of-age, English-fluent, not diagnosed with bipolar or psychotic disorders, and able to make their own medical decisions. Participants were 74.8% men, an average of 48.5 years (range 18.1-89.8 years), 76.2% White, 31.9% privately insured, and 64.7% making <$50,000 per year., Interventions: Not applicable., Main Outcome Measures: Exploratory analyses of screening data from a randomized controlled trial for pain treatment. Primary outcomes included pain intensity, pain interference, and the patient report of recommended pain treatments by a medical provider, tried by the patient, or that the patient would be willing to try., Results: More treatments recommended was associated with younger age (ρ=-0.14, 95% confidence interval [CI]: -0.01 to -0.27, P=.03) and private insurance (ρ=-0.15, 95% CI: 0.02-0.27, P=.03), whereas more treatments tried was associated with private insurance alone (ρ=0.20, 95% CI: 0.07-0.32, P=.003). Number of treatments willing to be tried was associated with lower income (ρ=-0.15, 95% CI: -0.02 to -0.28, P=.03). SCI patients of color (PoC) reported higher pain intensity (Cohen's d=0.41, 95% CI: 0.11-0.71) and greater odds of receiving psychotherapy for pain (odds ratio: 7.12, 95% CI: 1.25-40.46) than their White peers., Conclusions: These exploratory findings indicate differences in SCI-related pain intensity based on identifying as PoC, and differences in SCI-related pain treatment modalities based on identifying as PoC, age, insurance type, and income. Further work exploring differences in SCI-related pain care based on patient social identities is warranted., (Published by Elsevier Inc.)

Conducting high-quality clinical research is dependent on merging scientific rigor with the clinical environment. This is often a complex endeavor that may include numerous barriers and competing interests. Overcoming these challenges and successfully integrating clinical research programs into clinical practice settings serving rehabilitation outpatients is beneficial from both a logistical perspective (eg, supports efficient and successful research procedures) and the establishment of a truly patient-centered research approach. Leveraging our experience with navigating this research-clinical care relationship, this article (1) proposes the Patient-Centered Framework for Rehabilitation Research, a model for integrating patient-centered research in an outpatient clinical setting that incorporates a collaborative, team-based model encompassing patient-centered values, as well as strategies for recruitment and retention, with a focus on populations living with disabilities or chronic diseases; (2) describes application of this framework in a comprehensive specialty multiple sclerosis center with both general strategies and specific examples to guide adaptation and implementation in other settings; and (3) discusses the effect of the framework as a model in 1 center, as well as the need for additional investigation and adaptation for other populations. The 5 interconnected principles incorporated in the Framework and which prioritize patient-centeredness include identifying shared values, partnering with the clinical setting, engaging with the population, building relationships with individuals, and designing accessible procedures. The Patient-Centered Framework for Rehabilitation Research is a model presented as an adaptable roadmap to guide researchers in hopes of not only improving individual patients' experiences but also the quality and relevance of rehabilitation research as a whole. Future investigation is needed to test the Framework in other settings., (Copyright © 2022 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to examine same-day associations of pain, fatigue, depressed mood, anxiety, and perceived cognitive function with social participation in the daily lives of adults with spinal cord injury (SCI)., Design: Observational study used a combination of baseline surveys and 7 end-of-day (EOD) diaries., Setting: General community., Participants: Individuals with SCI (N=168; mean age, 49.8y; 63% male, 37% female)., Main Outcome Measures: Patient-Reported Outcomes Measurement Information System short form measures (Ability to Participate in Social Roles and Activities, Pain Intensity, Depression, Anxiety, Cognitive Function Abilities) were adapted for daily administrations as EOD diaries., Result: Results of multivariable model showed that daily increases in fatigue (B=-0.10; P=.004) and depressive symptoms (B=-0.25; P=<.001) and decreases in perceived cognitive function (B=0.11; P=<.001) were significantly related to worse same-day social participation. Daily fluctuations in anxiety and pain were unrelated to same-day social participation., Conclusions: This is the first study that shows within-person associations of common SCI symptoms with social participation in the daily lives of adults with SCI. Results from the current study may help to develop more effective individualized treatments of symptoms and symptom effect aimed at improving social participation., (Published by Elsevier Inc.)

Objective: Although sleep difficulties are common after spinal cord injury (SCI), little is known about how day-to-day fluctuations in sleep quality affects health-related quality of life (HRQOL) among these individuals. We examined the effect of sleep quality on same-day HRQOL using ecological momentary assessment methods over a 7-day period., Design: Repeated-measures study involving 7 days of home monitoring; participants completed HRQOL measures each night and ecological momentary assessment ratings 3 times throughout the day; multilevel models were used to analyze data., Setting: Two academic medical centers., Participants: A total of 170 individuals with SCI (N=170)., Interventions: Not applicable., Main Outcome Measures: Daily sleep quality was rated on a scale of 0 (worst) to 10 (best) each morning. Participants completed end-of-day diaries each night that included several HRQOL measures (Sleep Disturbance, Sleep-related Impairment, Fatigue, Cognitive Abilities, Pain Intensity, Pain Interference, Ability to Participate in Social Roles and Activities, Depression, Anxiety) and ecological momentary assessment ratings of HRQOL (pain, fatigue, subjective thinking) 3 times throughout each day., Results: Multilevel models indicated that fluctuations in sleep quality (as determined by end-of-day ratings) were significantly related to next-day ratings of HRQOL; sleep quality was related to other reports of sleep (Sleep Disturbance; Sleep-related Impairment; Fatigue) but not to other aspects of HRQOL. For ecological momentary assessment ratings, nights of poor sleep were related to worse pain, fatigue, and thinking. Generally, sleep quality showed consistent associations with fatigue and thinking across the day, but the association between sleep quality and these ecological momentary assessment ratings weakened over the course of the day., Conclusions: Findings highlight the important association between sleep and HRQOL for people with SCI. Future work targeting sleep quality improvement may have positive downstream effects for improving HRQOL in people with SCI., (Copyright © 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe pain intensity and interference in people with progressive multiple sclerosis (MS), compare these with people with relapsing-remitting multiple sclerosis (RRMS), and identify common and unique factors associated with pain intensity in people with progressive MS and RRMS., Design: Observational, cross-sectional analysis using baseline data from a longitudinal survey on quality of life in participants with MS., Setting: Community., Participants: A total of 573 adults with MS (N=573; progressive MS, n=142; RRMS, n=431)., Interventions: Not applicable., Main Outcome Measures: Average pain intensity was measured by an 11-point numeric rating scale, and pain interference was measured by the Patient-Reported Outcomes Measurement Information System Pain Interference Short Form., Results: Participants with progressive MS reported moderate average pain intensity (3.22±2.50) and elevated pain interference (T score of 55.55±9.13). They did not differ significantly from those with RRMS in average pain intensity or pain interference. Common factors associated with higher average pain intensity were more severe disability, lower education level, unemployment, and current smoking. In those with progressive MS, older age was associated with lower average pain intensity., Conclusions: Pain intensity and interference are similar across MS types. In addition to assessing and treating pain, it is important to screen for modifiable pain-related factors, such as smoking cessation, in this population., (Copyright © 2021 The American Congress of Rehabilitation Medicine. All rights reserved.)

Objective: To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system., Design: Randomized controlled trial with masked outcome assessment., Setting: Five Veterans Affairs medical centers geographically dispersed across the United States., Participants: 147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147)., Interventions: Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested., Main Outcome Measures: Primary outcomes were physical functioning (Short Musculoskeletal Functional Assessment) and psychosocial functioning (Patient Health Questionnaire-9). Secondary outcomes were quality of life (global) and quality of life (satisfaction with health) from the World Health Organization Quality of Life Scale (brief). Assessment was conducted at baseline, 6 weeks (treatment completion), and 6 months (follow-up)., Results: Participants randomized to VETPALS reported significantly improved psychosocial functioning and quality of life (satisfaction with health) relative to controls at 6 months (B=1.84; 95% confidence interval, 0.37,3.31 and B=-0.61; 95% confidence interval, -1.11,-0.12, respectively). There were no differences in physical functioning over time between VETPALS and education control at either time point. Follow-up multiple imputation sensitivity analyses produced an identical pattern of results. Among VETPALS participants, treatment initiation was low (56%), but treatment retention (93% attended 4 of 5 classes) and overall satisfaction (100% reported very helpful or better and would recommend to a friend) were high., Conclusions: Group-based self-management improves psychosocial functioning for individuals with amputation due to chronic limb threatening ischemia. In-person participation is challenging for this population, but individuals who successfully initiate treatment typically persist and are highly satisfied., (Published by Elsevier Inc.)

Objectives: To (1) describe depressive symptom severity and suicidal ideation (SI) in persons with progressive multiple sclerosis (MS); (2) compare depressive symptom severity and SI in persons with progressive MS and persons with relapsing-remitting multiple sclerosis (RRMS); and (3) identify common and unique risk factors for greater depressive symptom severity and SI in persons with progressive MS compared with individuals with RRMS., Design: Observational, cross-sectional survey study., Setting: Community., Participants: Adults with MS (N=573)., Interventions: Not applicable., Main Outcome Measures: The dependent variables were depression symptoms and any SI measured by the Patient Health Questionnaire-9. Comparisons between groups used t tests and chi-square analyses, and risk factors were tested by examining the interaction of MS subtype (progressive MS and RRMS) and each risk factor in multiple regression models with bootstrapping., Results: Persons with progressive MS did not differ from persons with RRMS in levels of depressive symptoms or SI. Both groups reported mild depressive symptoms and approximately 10% endorsed SI. Common risk factors for greater depressive symptom severity were younger age, greater disability, greater speech and swallowing problems, and lower household income. Common risk factors for SI were shorter disease duration, greater disability, and greater speech and swallowing problems., Conclusions: In this sample, there were no group differences between persons with progressive MS and persons with RRMS in depressive symptom severity and SI. Although both groups reported mild depressive symptoms on average, nearly 1 in 4 persons met criteria for probable major depression, which underscores the importance of screening for and treating depressive disorders in all persons with MS., (Copyright © 2020 American Congress of Rehabilitation Medicine. All rights reserved.)

Objective: To examine moderators of treatment effects in a randomized controlled trial comparing a telehealth self-management intervention with a telehealth multiple sclerosis (MS) education intervention for fatigue, pain, and mood in adults with MS., Design: Secondary analysis of a single-blind randomized controlled trial., Setting: Community., Participants: Adults with MS and chronic fatigue, chronic pain, and/or moderate depressive symptoms (N=163) recruited from across the United States., Interventions: Two 8-week, telephone-delivered symptom interventions delivered 1:1: a self-management intervention (n=75) and an MS education intervention (n=88)., Main Outcome Measures: Outcome measures were fatigue impact pain interference, and depressive symptom severity assessed at baseline and posttreatment. Potential moderators of treatment effects assessed at baseline were demographics (age, sex, and education), clinical characteristics (disease duration and disability severity), symptoms (perceived cognitive impairment and pain intensity), baseline levels of the treatment outcomes (pain interference, fatigue impact and depressive symptom severity), and cognitive behavioral factors (pain catastrophizing, fatigue catastrophizing, self-efficacy, and patient activation)., Results: Moderation analyses found significant moderation for fatigue impact but not for pain intensity or depressive symptom severity. Baseline patient activation interacted with treatment group to predict fatigue impact at posttreatment (P=.049). Among participants with high baseline patient activation, the self-management group reported significantly less fatigue at posttreatment than the education group. No other variables moderated the study outcomes., Conclusions: At the group level, participants responded to both interventions, regardless of disease characteristics, demographics, symptom levels, and cognitive behavioral factors. Self-management and education are both potentially beneficial symptom treatments that may be recommended to individuals with MS and chronic pain, fatigue, and/or depressive symptoms., (Copyright © 2018 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine if resilience is uniquely associated with functional outcomes (satisfaction with social roles, physical functioning, and quality of life) in individuals with physical disabilities, after controlling for measures of psychological health (depression and anxiety) and symptom severity (pain, fatigue, and sleep disturbance); and to examine the potential moderating effect of sex, age, and diagnosis on the hypothesized associations between resilience and function., Design: Cross-sectional survey study., Setting: Surveys were mailed (81% response rate) to a community sample of 1949 individuals with multiple sclerosis, muscular dystrophy, postpoliomyelitis syndrome, or spinal cord injury. Participants were recruited through the Internet or print advertisement (28%), a registry of previous research participants who indicated interest in future studies (21%), a departmental registry of individuals interested in research (19%), disability-specific registries (18%), word of mouth (10%), or other sources (3%)., Participants: Convenience sample of community-dwelling adults aging with physical disabilities (N=1574), with a mean Connor-Davidson Resilience Scale (10 items) score of 29., Interventions: Not applicable., Main Outcome Measures: Patient-Reported Outcomes Measurement Information System measures of Satisfaction with Social Roles and Activities and Physical Functioning, the World Health Organization's brief Older People's Quality of Life Questionnaire, and the Connor-Davidson Resilience Scale (10 items)., Results: After controlling for age, age squared, sex, diagnosis, psychological health, and symptom severity, resilience was significantly and positively associated with satisfaction with social roles (β=.17, P<.001) and quality of life (β=.39, P<.001), but not physical function (β=.04, P>.05). For every 1-point increase in scores of resilience, there was an increase of .50 in the quality of life score and .20 in the satisfaction with social roles score. Sex also moderated the association between resilience and satisfaction with social roles (F 1,1453 =4.09, P=.043)., Conclusions: The findings extend past research, providing further evidence indicating that resilience plays a unique role in nonphysical functional outcomes among individuals with physical disabilities., (Copyright © 2016 American Congress of Rehabilitation Medicine. All rights reserved.)

Objectives: To investigate the longitudinal relationships between social support and subsequent mental health outcomes in individuals with multiple sclerosis (MS), and to examine resilience as a mediator between social support and subsequent mental health outcomes in this population., Design: Observational, longitudinal cohort study. Participants were assessed at 4 time points over 12 months in the context of a previously reported randomized controlled trial., Setting: Telephone-based measures administered to community-based participants., Participants: Individuals (N=163) with MS and 1 or more of the following symptoms: depression, fatigue, and pain., Interventions: Not applicable., Main Outcome Measures: Mental health outcomes included (1) depressive symptomatology, assessed using the Patient Health Questionnaire-9; (2) anxious symptomatology, assessed using the short form of the Emotional Distress-Anxiety Scale from the Patient-Reported Outcomes Measurement Information System; and (3) general mental health status, assessed using the Mental Component Summary score from the Short Form-8 Health Survey. Resilience was assessed using the Connor-Davidson Resilience Scale., Results: At any given time, social support from significant others, family members, and friends was significantly associated with subsequent mental health outcomes for all 3 measures assessed (all P values <.05). Resilience measured concomitantly with social support significantly mediated the relationships between social support and subsequent mental health outcomes. After controlling for resilience, most of the direct relationships between social support and mental health outcomes were no longer significant., Conclusions: There are significant longitudinal relationships between social support, resilience, and mental health outcomes for people with MS. Given the mediating role of resilience in supporting better mental health outcomes, future clinical research and practice may benefit from an emphasis on resilience-focused psychological interventions., (Copyright © 2016 American Congress of Rehabilitation Medicine. All rights reserved.)

Objectives: (1) To determine if resilience exhibits similar stability across time as depression, fatigue, and sleep quality; and (2) to determine if changes in resilience over a period of 1 year are associated with changes in depression, fatigue, sleep quality, and physical function over the same time period., Design: Observational longitudinal survey study with measures administered 2 times, 1 year apart., Setting: Community-based population sample., Participants: Adults with physical disabilities (N=893)., Interventions: Not applicable., Main Outcome Measures: Primary outcomes were measures of resilience (Connor-Davidson Resilience Scale), depression (Patient Health Questionnaire-9), fatigue (Patient-Reported Outcomes Measurement Information System [PROMIS] Fatigue Short Form), sleep quality (PROMIS Sleep Disturbance), and physical function (8-item PROMIS Physical Functioning)., Results: Resilience (r=.71, P<.001) exhibited similar stability over 1 year to depression (r=.71, P<.001), fatigue (r=.79, P<.001), and sleep quality (r=.68, P<.001). A decrease in resilience was associated with an increase in depression (F 1,885 =70.23; P<.001; R 2 =.54) and fatigue (F 1,885 =25.66; P<.001; R 2 =.64), and an increase in resilience was associated with improved sleep quality (F 1,885 =30.76; P<.001; R 2 =.48) and physical function (F 1,885 =16.90; P<.001; R 2 =.86) over a period of 1 year, while controlling for age, sex, and diagnosis., Conclusions: Resilience exhibits similar test-retest stability as other important domains that are often treatment targets. Changes in resilience were associated with changes in depression, fatigue, sleep quality, and physical functioning over the course of 1 year. Further longitudinal and experimental research is warranted to investigate the potential causal effect of changes in resilience on quality of life in individuals with physical disabilities., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether baseline levels of pain, fatigue, sleep disturbance, and physical activity measured at the initial assessment predicted the development of or improvement of depression 3.5 years later, while controlling for sex, age, and disease severity., Design: Observational, longitudinal survey study., Setting: A community-based population sample., Participants: Adults with multiple sclerosis (MS) (N=489)., Interventions: Not applicable., Main Outcome Measure: Primary outcome was classification of depression group measured using a Patient Health Questionnaire-9 cutoff score ≥10, indicating probable major depression., Results: Fatigue severity (odds ratio, 1.19; 95% confidence interval, 1.12-1.26; P<.0001) and sleep disturbance (odds ratio, 1.06; 95% confidence interval, 1.02-1.10; P=.001) predicted probable major depression 3.5 years later among those not depressed at the initial assessment. An effect of age (odds ratio, .96; 95% confidence interval, .92-.99; P=.008) was found among those who developed depression, indicating that younger adults were more likely to develop depression. Pain, fatigue, sleep, and physical activity at baseline were not significantly associated with recovery from depression among those depressed at the initial assessment., Conclusions: Fatigue and sleep may contribute to the development of depression. Clinical trial research targeting these variables to determine their influence on depression is warranted., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the frequency and severity of 8 symptoms in persons with multiple sclerosis (MS) and to examine the association between these symptoms and community integration and mental health., Design: Cross-sectional survey that assessed 8 symptoms (pain, fatigue, imbalance, numbness, weakness, shortness of breath, vision loss, and memory loss), disease progression (self-report version of the Expanded Disability Status Scale), community integration, and mental health., Setting: Community., Participants: Adults with self-reported MS who responded to a mailed survey (N=180)., Interventions: Not applicable., Main Outcome Measures: The presence and intensity of symptoms were measured with a symptoms checklist. Community integration was assessed with the Community Integration Questionnaire, and mental health was measured by the Mental Health Index of the Medical Outcomes Study 36-Item Short-Form Health Survey., Results: The average number of symptoms reported was 5.07±2.18. The most common symptoms (fatigue, weakness, and imbalance) were also rated as the most severe. Not all symptoms were associated with level of disease progression or with MS subtype. Symptoms related to mobility were more likely to be associated with these variables. The 8 symptoms as a whole accounted for significant amounts of variance (range, 13%-21%) in measures of community integration and mental health, with specific symptoms making differential independent contributions to these measures., Conclusions: This study demonstrates that most individuals with MS report a number of bothersome symptoms. Type of MS or level of progression does not tell the whole story regarding the impact of symptoms., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the efficacy of a telephone-delivered self-management intervention for fatigue, pain, and depression in adults with multiple sclerosis (MS)., Design: Single-center, randomized (1:1), single-blind (outcome assessors), parallel-group trial with a primary endpoint of posttreatment (9-11 wk postrandomization) and long-term follow-up at 6 and 12 months., Setting: Telephone-delivered across the United States., Participants: Adults with MS (N=163) with fatigue, chronic pain, and/or moderate depressive symptoms (age range, 25-76 y)., Interventions: Eight-week individual telephone-delivered self-management intervention (T-SM) (n=75) versus an 8-week individual telephone-delivered MS education intervention (T-ED) (n=88)., Main Outcome Measures: The primary outcome was the proportion who achieved a ≥50% decrease in 1 or more symptoms-fatigue impact, pain interference, and/or depression severity. Secondary outcomes included continuous measures of pain, fatigue impact, depression, self-efficacy, activation, health-related quality of life, resilience, and affect., Results: For our primary outcome, 58% of those in the T-SM group and 46% of those in the T-ED group had a ≥50% reduction in 1 or more symptoms; this difference was not statistically significant (odds ratio, 1.50; 95% confidence interval, .77-2.93; P=.238). Participants in both groups significantly improved from baseline to posttreatment in primary and secondary outcome measures (P<.05). T-SM participants reported significantly higher treatment satisfaction and therapeutic alliance and greater improvements in activation, positive affect, and social roles. Improvements were generally maintained at 6 and 12 months., Conclusions: Both interventions resulted in short- and long-term, clinically meaningful benefits. The study demonstrated that the telephone is an effective method for engaging participants in care and extending the reach of rehabilitation for individuals with MS., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine headache trajectories among persons with mild traumatic brain injury (MTBI) in the year after injury and the relation of headache trajectory to posttraumatic stress disorder (PTSD) at 1 year postinjury., Design: Prospective, longitudinal study., Setting: Participants were recruited through a university medical center and participated in follow-up assessments by telephone., Participants: Prospectively enrolled individuals (N=212) within 1 week of MTBI who were hospitalized for observation or other system injuries. Participants were assessed at baseline and 3, 6, and 12 months postinjury., Interventions: Not applicable., Main Outcome Measures: Participants rated average headache pain intensity using the 0 to 10 numerical rating scale at each assessment period. The PTSD Checklist-Civilian Version was completed at 12 months postinjury., Results: Latent class growth analysis produced a 4-trajectory group model, with groups labeled resolved, worsening, improving, and chronic. Multivariate regression modeling revealed that younger age and premorbid headache correlated with membership in the worse trajectory groups (worsening and chronic; P<.001). Univariate regression revealed a significant association between PTSD and membership in the worse trajectory groups (P<.001)., Conclusions: Headache is common in the year after MTBI, with younger people, persons who previously had headaches, and persons with PTSD more likely to report chronic or worsening headache. Further research is needed to examine whether PTSD symptoms exacerbate headaches or whether problematic headache symptoms exacerbate PTSD., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the links between resilience and depressive symptoms, social functioning, and physical functioning in people aging with disability and to investigate the effects of resilience on change in functional outcomes over time., Design: Longitudinal postal survey., Setting: Surveys were mailed to a community sample of individuals with 1 of 4 diagnoses: multiple sclerosis, muscular dystrophy, postpoliomyelitis syndrome, or spinal cord injury. The survey response rate was 91% at baseline and 86% at follow-up., Participants: A convenience sample of community-dwelling individuals (N=1594; age range, 20-94y) with multiple sclerosis, muscular dystrophy, postpoliomyelitis syndrome, or spinal cord injury., Interventions: Not applicable., Main Outcome Measures: Patient Health Questionnaire-9 (to assess depressive symptoms) and Patient Reported Outcomes Measurement Information System (to assess social role satisfaction and physical functioning)., Results: At baseline, resilience was negatively correlated with depressive symptoms (r=-.55) and positively correlated with social and physical functioning (r=.49 and r=.17, respectively). Controlling for baseline outcomes, greater baseline resilience predicted a decrease in depressive symptoms (partial r=-.12) and an increase in social functioning (partial r=.12) 3 years later., Conclusions: The findings are consistent with a view of resilience as a protective factor that supports optimal functioning in people aging with disability., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether self-efficacy longitudinally predicts 2 types of perceived cognitive impairment (PCI) in multiple sclerosis (MS): general cognitive functioning and executive functioning; and secondarily to assess whether self-efficacy mediates the relationships between depression, fatigue, and PCI., Design: Longitudinal analysis of self-report survey data collected over 3 years. Hierarchical regression analyses examined the relationship between self-efficacy and PCI, adjusting for depression and fatigue. Additional analyses tested self-efficacy as a mediator between depression, fatigue, and PCI., Setting: Community., Participants: Community-dwelling individuals with MS (N=233; age range, 22-83y) were recruited from a larger longitudinal survey study of individuals with MS (N=562)., Interventions: Not applicable., Main Outcome Measures: Primary outcome measures were the Applied Cognition-General Concerns and the Applied Cognition-Executive Function domains of the Quality of Life in Neurological Disorders (NeuroQoL) measures., Results: Self-efficacy was significantly correlated with PCI at baseline (r=.40-.53) and 3 years later (r=.36-.44). In multivariate regression analyses, self-efficacy was a significant longitudinal predictor of PCI, both for general cognitive functioning (β=.20, P<.01) and executive functioning (β=.16, P<.05). Self-efficacy partially mediated the relationships between depression, fatigue, and PCI., Conclusions: Self-efficacy may influence how individuals with MS perceive their cognitive functioning over time. Interventions that target self-efficacy, particularly early in the disease course, may lead to improvements in PCI, as well as improvements in fatigue and depression., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To compare a multicomponent motivational interviewing (MI)/self-management (SM) intervention with a multicomponent education intervention to improve skin-protective behaviors and prevent skin worsening in veterans with spinal cord injury (SCI) hospitalized for severe pressure ulcers (PrUs)., Design: Single-blinded, prospective, randomized controlled trial., Setting: Six Veterans Affairs SCI centers., Participants: Veterans admitted for a severe (stage III/IV) PrU were followed up to 6 months postdischarge., Intervention: Telephone-based individual MI counseling plus SM skills group (SM+MI; n=71) versus an active control group of telephone-based individual educational counseling plus group education (n=72)., Main Outcome Measures: Self-reported skin-protective behaviors, objective skin worsening., Results: Intention-to-treat analyses found nonsignificant increases in skin behaviors in the SM+MI versus education control intervention arms at 3 and 6 months. The difference in behaviors used between SM+MI and education control intervention participants was 4.6% (95% confidence interval [CI], -11.3 to 2.7) (0-3mo) and 3.0% (95% CI, -8.7 to 3.9) (0-6mo). High rates of skin worsening were observed (n=74, 51.7%), usually within 3 months postdischarge and most frequently within the month postdischarge. Skin worsening, skin-related visits, and readmissions did not differ by study arm. Study limitations are presented., Conclusions: For persons with chronic SCI and severe PrUs, complicated by multiple comorbidities, a primary focus on improving patient behavior is likely insufficient to address the complex problem of PrUs in SCI. More health care systems-level changes such as collaborative care may be needed to reduce PrU recurrence, especially in this era in which many people are discharged from the hospital unhealed or with little sitting tolerance., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the prevalence of pain, depression, and comorbid pain and depression among a civilian sample of persons with traumatic brain injury (TBI)., Design: Longitudinal survey design with 1-year follow-up., Setting: Inpatient rehabilitation and the community., Participants: Participants (N=158) admitted to inpatient rehabilitation after moderate to severe TBI., Interventions: Not applicable., Main Outcome Measures: Depression was assessed with the Patient Health Questionnaire-9 (PHQ-9); pain was assessed with a numerical rating scale from 0 (no pain) to 10 (worst pain). Participants who reported average pain ≥ 4 were classified as having pain, and participants with PHQ-9 scores ≥ 10 were classified as depressed., Results: Both pain and depression were more prevalent at baseline assessment (pain: 70%; depression: 31%) than at year 1 (pain: 34%; depression: 22%). Comorbid pain and depression declined from 27% at baseline to 18% at year 1. Pain was significantly associated with depression at baseline (relative risk: 2.62, P=.003) and at year 1 (relative risk: 7.98, P<.001)., Conclusions: Pain and depression are common and frequently co-occur in persons with TBI. Although their frequency declined over the first year after injury, the strength of their association increased. Assessment and treatment of both conditions simultaneously may lead to improved outcomes, both early after TBI and over time., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Few published intervention studies in the rehabilitation literature have included consumers in the research process other than as study participants. This lack of consumer involvement in intervention research may contribute to the challenges encountered developing, translating, disseminating, and sustaining evidence-based rehabilitation interventions in clinical practice. The overall objective of this article is to promote the integration of participatory action research (PAR) into rehabilitation intervention research as a mechanism for addressing these gaps. First, we outline essential components of a PAR model across 5 key phases of intervention research, specifically: agenda setting, methods, implementation, diffusion/dissemination, and sustainability. Second, we describe the use of PAR in rehabilitation intervention research within each of these phases by reviewing relevant literature and by providing an illustrative research example from a randomized controlled trial that integrated PAR throughout the research process. Finally, we conclude with a discussion of 5 specific recommendations for promoting the integration of PAR into rehabilitation intervention research., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To systematically review the research findings regarding the associations between psychosocial factors and adjustment to chronic pain in persons with physical disabilities., Data Sources: A key word literature search was conducted using articles listed in PubMed, PsychInfo, and CINAHL up to March 2010, and manual searches were made of all retrieved articles to identify published articles that met the review inclusion criteria., Study Selection: To be included in the review, articles needed to (1) be written in English, (2) include adults with a physical disability who report having pain, (3) include at least 1 measure of a psychosocial predictor domain, (4) include at least 1 criterion measure of pain or patient functioning, and (5) report the results of associations between the psychosocial factors and criterion measures used in the study. Twenty-nine studies met the inclusion criteria., Data Extraction: Three reviewers tabulated study details and findings., Data Synthesis: The disability groups studied included spinal cord injury (SCI), acquired amputation, cerebral palsy (CP), multiple sclerosis (MS), and muscular dystrophy (MD). Psychosocial factors were shown to be significantly associated with pain and dysfunction in all disability groups. The psychosocial factors most closely associated with pain and dysfunction across the samples included (1) catastrophizing cognitions; (2) task persistence, guarding, and resting coping responses; and (3) perceived social support and solicitous responding social factors. Pain-related beliefs were more strongly associated with pain and dysfunction in the SCI, CP, MS, and MD groups than in the acquired amputation group., Conclusions: The findings support the importance of psychosocial factors as significant predictors of pain and functioning in persons with physical disabilities. Clinical trials to test the efficacy of psychosocial treatments for pain and dysfunction are warranted, as are studies to determine whether psychosocial factors have a causal influence on pain and adjustment in these populations., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize the prevalence and impact of pain in veterans with multiple sclerosis (MS) and to assess their association with demographic, biologic, and psychologic variables., Design: Cross-sectional cohort study linking computerized medical record information to mailed survey data., Setting: Veterans Health Administration (VHA)., Participants: Sixty-four percent (2994/4685) of veterans with MS who received services in VHA and also returned survey questionnaires., Interventions: Not applicable., Main Outcome Measures: Items assessing pain intensity, pain interference, and physical and mental health functioning., Results: Ninety-two percent of participants reported bodily pain within the prior 4 weeks, with 69% of the total sample indicating pain of moderate or higher intensity. Eighty-five percent indicated that pain caused functional interference during the past 4 weeks, with 71% of the total sample reporting pain-related interference that was moderate or greater. No significant sex or race differences emerged for the pain indices. A significant but modest relationship between increasing age and pain interference emerged (r=.05, P<.01); however, age was not significantly related to pain intensity. Multivariate regression analyses identified pain intensity (beta=.73), physical health functioning (beta=-.07), and mental health functioning (beta=-.13) variables as significant, unique contributors to the prediction of pain interference. The interaction of pain intensity and physical functioning was also significant but of minimal effect size (beta=-.03)., Conclusions: Pain is highly prevalent and causes substantial interference in the lives of veterans with MS. The functional impact of pain in veterans with MS is influenced by pain intensity, physical health, and emotional functioning. Clinical practice should take each of these domains into consideration and reflect a biopsychosocial conceptualization.

Objective: To examine the types and relative frequency of treatments used for lower-limb phantom limb pain (PLP), including both pharmacologic and rehabilitative interventions., Design: Cross-sectional survey., Setting: Community-based survey from clinical databases., Participants: Community-based sample (N=255) of persons with lower-limb amputations., Interventions: Not applicable., Main Outcome Measures: Intensity of PLP and type and helpfulness of treatments (both past and present) used for PLP., Results: Although 72% of the sample (n=183) reported current PLP, 53% of the respondents with PLP (and 38% of those with severe PLP) had never used treatment for PLP. Those who had used treatment reported greater pain severity and interference. The most commonly used treatment modality was analgesic medication, including acetaminophen, opioids, and nonsteroidal anti-inflammatory drugs. Of the treatments surveyed, only opioids and chiropractic care were rated as moderately to extremely helpful by the majority of those who had tried them, and many pain interventions had been discontinued., Conclusions: As hypothesized, a significant proportion of persons with PLP have not used treatment for this pain, and, among those who have used pain treatments, few treatments are perceived as substantially helpful. More research is needed to identify effective management strategies for PLP and to examine further patient perceptions of pain treatment.

Objectives: To identify common pain descriptors used by people with physical disability-related pain and to suggest words that are likely to prompt responses in clinical interviews and assessments., Design: Open-ended interviews were coded and then contrasted with responses to a pain questionnaire, obtained through mail or interview surveys., Setting: Rehabilitation research program., Participants: Twenty-eight people with physical disability-related pain in a series (n=54) of in-depth interviews and 1053 participants with disabilities who responded to mailed questionnaires or structured interviews about pain and its impact (459 with acquired lower-limb amputation, 471 with spinal cord injury, 123 with cerebral palsy)., Interventions: Not applicable., Main Outcome Measures: Pain interview descriptions and McGill Pain Questionnaire (MPQ)., Results: Different pain experiences were reflected in narrative descriptions and self-report questionnaire responses. We report the common terms, but across diagnoses use of terms does not appear to clearly differentiate distinct pain phenomenon. Narrative interviews support the use of several MPQ pain descriptors. However, discrete descriptors are recommended when assessing adults with physical disability., Conclusions: We identified pain descriptors that appear to be most useful in assessing daily life and participation experiences with physical disability-related pain. These may be clinically useful, but caution is advised when doing diagnostic workups based solely on sensory and affective pain descriptions.

Objective: To evaluate whether amitriptyline is more effective than placebo in improving phantom limb pain or residual limb pain., Design: Randomized controlled trial of amitriptyline for 6 weeks., Setting: University hospital., Participants: Thirty-nine persons with amputation-related pain lasting more than 6 months., Intervention: Six-week trial of amitriptyline (titrated up to 125 mg/d) or an active placebo (benztropine mesylate)., Main Outcome Measures: Analyses were conducted to examine whether there was a medication group effect on the primary outcomes (average pain intensity) and secondary outcome measures (disability, satisfaction with life, handicap)., Results: No significant differences were found between the treatment groups in outcome variables when controlling for initial pain scores., Conclusions: Our findings do not support the use of amitriptyline in the treatment of postamputation pain.

Objective: To determine the association between pain site and pain interference with activities of daily living (ADLs) among persons with acquired amputation., Design: Survey., Setting: Community-based survey from clinical databases, flyer postings, and an advertisement in the inMotion magazine., Participants: Persons with lower-limb amputations (N=478)., Interventions: Six or more months after lower-limb amputation, participants completed an amputation pain questionnaire that included several standardized pain measures., Main Outcome Measures: Numeric rating scale measures of average phantom limb, residual limb, and back pain and pain-related impairment as measured by a modified version of the Pain Interference Scale of the Brief Pain Inventory., Results: Phantom limb, residual limb, and back pain intensity ratings, as a group, accounted for 20% of the variance in pain interference. The pain intensity ratings associated with each individual pain site made a statistically significant contribution to the prediction of pain interference with ADLs even after controlling for the pain intensity of the other 2 sites., Conclusions: Pain in each of 3 sites (phantom limb, residual limb, back) appears to be important to pain-related impairment and function. Measurement of the intensity of pain at each site appears to be required for a thorough assessment of amputation pain-related impairment., (Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation)

Objective: To evaluate the frequency, duration, intensity, and interference of back pain in a sample of persons with lower limb amputations., Design: Retrospective, cross-sectional survey., Setting: Community-based survey from clinical databases., Participants: Participants who were 6 or more months post lower limb amputation (n = 255)., Intervention: An amputation pain survey that included several standardized pain measures., Main Outcome Measures: Frequency, duration, intensity, and interference of back pain., Results: Of the participants who completed the survey (return rate, 56%), 52% reported experiencing persistent, bothersome back pain. Of these, 43% reported average back pain intensity in the mild range (1-4 on 0-10 rating scale) and 25% reported pain of moderate intensity (5-6 on 0-10 scale). Most respondents with back pain rated the interference of their pain on function as none to minimal. However, nearly 25% of those with back pain described it as frequent, of severe intensity (>or=7 on 0-10 scale), and as severely interfering with daily activities including social, recreational, family, and work activities., Conclusions: Back pain may be surprisingly common in persons with lower limb amputations, and, for some who experience it, may greatly interfere with function.

Objectives: To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain, and to evaluate pain-related disability associated with phantom limb pain., Design: Retrospective, cross-sectional survey. Six or more months after lower limb amputation, participants (n = 255) completed an amputation pain questionnaire that included several standardized pain measures., Setting: Community-based survey from clinical databases., Participants: A community-based sample of persons with lower limb amputations., Main Outcome Measures: Frequency, duration, intensity, and quality of phantom limb and residual limb pain, and pain-related disability as measured by the Chronic Pain Grade., Results: Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. Many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%)., Conclusions: Phantom limb and residual limb pain are common after a lower limb amputation. For most, the pain is episodic and not particularly disabling. However, for a notable subset, the pain may be quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning.