Against all odds: positive life experiences of people with advanced amyotrophic lateral sclerosis

Biographical work and returning to employment following a spinal cord injury

The question of returning to work after the onset of severe impairment is inseparable from the biographical work that disabled people need to achieve. Qualitative analysis of interviews I carried out among people who had become paraplegic and among rehabilitation professionals offered the following insights: * During a period extending beyond rehabilitation, interviewees were absorbed by the work of coming to terms with their impairment and delegated the question of occupation to the professionals. At a later date, some of them manage to recast their biographies and gain ownership of their occupations and activities for themselves. An open environment, which offers negotiable opportunities and space for relationships to form, encourages the development of biographical work. Nowadays, the question of exclusion would appear to dominate the domain of rehabilitation. The belief that prolonged inactivity engenders marginalisation has led professionals to develop a doctrine whereby they encourage their patients to plan for their professional activities from a very early stage. Struggling with different time demands (for example, lengthy administrative procedures and reduced rehabilitation time) professionals organise their work around a new time frame which conflicts with their expertise and is difficult to reconcile with the trajectories of disabled people.

A cross sectional study on determinants of quality of life in ALS

BACKGROUND

Understanding the determinants of quality of life (QoL) in amyotrophic lateral sclerosis (ALS) has become increasingly important with the recent emphasis on the comprehensive management of patients.

OBJECTIVE

To evaluate the determinants of QoL in ALS using two scales with different theoretical constructs: the Schedule for the Evaluation of QoL-Direct Weighting (SEIQoL-DW), which evaluates subjective aspects of QoL, and the McGill QoL Questionnaire (MQOL), which evaluates both health related and non-health related factors of QoL.

METHODS

Eighty consecutive patients with ALS underwent a battery of tests evaluating QoL and a series of physical, emotional, psychological, and socioeconomic predictor variables. A stepwise linear regression model was used to compare QoL scores and explicatory variables.

RESULTS

SEIQoL-DW score was related to social support, depression, religiosity, and socioeconomic status. Total MQOL score was related to social support, socioeconomic status, and clinical status. MQOL single item score (MQOL-SIS) was related to social support, depression, social withdrawal, and socioeconomic status. SEIQoL-DW score was not related to total MQOL score. Conversely, a significant correlation was found between SEIQoL-DW and MQOL-SIS.

CONCLUSIONS

With both QoL scales, the most important explicatory variable of QoL was the self perceived quality of social support. Physical status was not relevant in determining QoL. This study indicates that health related QoL measures are not adequate to assess QoL in patients with ALS, because their appreciation of QoL mainly relies on psychological, supportive, and spiritual factors. Therapeutic interventions should consider the psychological needs of patients and pay greater attention to caregivers' issues.

Quality of life among people with high spinal cord injury living in the community

STUDY DESIGN

An exploratory, qualitative methodology.

OBJECTIVES

To explore perceptions of quality of life (QOL) among community-dwelling people with high spinal cord injuries (SCI) and the factors they identified as contributing to, enabling or constraining the quality of their lives.

SETTING

Urban communities on Vancouver Island and in the lower mainland of British Columbia, Canada.

METHODS

Semi-structured interviews with both men (n=11) and women (n=4) with complete high SCI (C1-C4). Interpretive analysis was grounded in the themes that arose from the interview transcripts.

RESULTS

Time since injury ranged from 4 to 28 years. The mean current age was 35 years, with a range from 21 to 50 years of age. High SCI disrupted not just a body but an entire biography of plans, daily activities and valued occupations. Initially feeling helpless and useless, the participants were unanimously glad to be alive at the time of the study and several described perceptions of very high QOL. The themes which emerged from the data were over-lapping and inter-dependent and described a process of refocusing values and re-establishing a view of the self as able and valuable following injury. The three primary themes addressed issues of autonomy, the meaningful use of time, and relationships.

CONCLUSIONS

The study findings suggest that life with a high SCI can be rich and fulfilling if society is prepared to enable and support this; and that QOL outcomes might be maximized by adopting a biographical orientation to the rehabilitation process.

SPONSORSHIP

This research was funded by a University of British Columbia Graduate Fellowship, a studentship from the Rick Hansen Man in Motion Foundation and a doctoral fellowship from the Social Sciences and Humanities Research Council of Canada.

"Sticking jewels in your life": exploring women's strategies for negotiating an acceptable quality of life with multiple sclerosis

The authors explored women's strategies for achieving quality of life with multiple sclerosis (MS) through interviews with 27 women, most of whom had lived with MS for more than 5 years. Analysis of the semistructured interviews followed the interpretative phenomenological approach. The women portrayed living with MS as an ongoing process of negotiation and described gaining quality of life through looking after health; maintaining meaningful occupations and roles; establishing mutual relationships; clarifying beliefs, aspirations, and philosophy of life; activism on disability issues; consciously valuing positive life experiences; and finding benefits in adversity. Despite recounting resourceful strategies, many acknowledged ongoing difficulties. Some narratives suggested a mesh or tapestry of coexisting positive and negative experiences. Others portrayed an adversarial relationship, with the positive and negative forces in their lives constantly battling for supremacy. A wide array of flexible, evolving strategies was required to achieve an acceptable quality of life with MS.

Quality of Life in Patients with Amyotrophic Lateral Sclerosis: Perceptions, Coping Resources, and Illness Characteristics

OBJECTIVE

To assess and compare quality of life (QOL) for two groups of patients with amyotrophic lateral sclerosis (ALS): (1) those reporting a more positive quality of life and (2) those reporting a more negative quality of life.

METHODS

One hundred patients with ALS participated in this cross-sectional, descriptive study conducted in an ALS clinic. Quality of life was graded in two ways: (1) a global question about present QOL, giving four choices (life could not be better, usually good, sometimes good, and not good) which the researchers divided into two groups: the more positive QOL and the more negative QOL and (2) patients' responses to a 25-item internally generated open-ended survey. The Appel ALS Rating Scale measured objective data for physical strength and functioning.

RESULTS

One hundred patients (68 men and 32 women) with a mean age of 58.2 (range, 29-82) years participated in the study. The average disease duration was 1.9 (range, 0.08-15) years. Patients who reported the more positive QOL were younger, had a shorter disease duration, and experienced less disease severity (p < 0.05). Those endorsing the more positive QOL reported more adequate finances and less stress over disease characteristics (p < 0.05).

CONCLUSIONS

Illness characteristics do influence QOL for patients with ALS, but they are not the only concerns. When measuring QOL in patients with ALS, the unique features of the psychosocial factors, personality traits, and spiritual factors, in addition to disease symptoms, need to be identified and discussed with patients and families throughout the illness.

Amyotrophic lateral sclerosis and hopelessness: psychosocial factors

The purpose of this study was to investigate the relationship of psychosocial factors to the presence of hopelessness among patients with amyotrophic lateral sclerosis (ALS). Secondary cross-sectional analyses were conducted with data collected from 136 ALS patients. Primary research questions were examined using hierarchical multiple regression procedures. Results showed that health locus of control and purpose in life were significant predictors of hopelessness among ALS patients. Other factors, including socioeconomic and demographic variables, variables measuring length and severity of illness, and additional psychosocial variables (social support satisfaction and degree to which spiritual beliefs help to cope with ALS) were not significant predictors of hopelessness. Results are discussed in light of the benefit to ALS patients of psychosocial interventions in disease management.

Subjective experience and coping in ALS

OBJECTIVE

Amyotrophic lateral sclerosis is a rapidly progressive and fatal disease which has no known cure and limited symptomatic treatment. While coping strategies in more common diseases are widely assessed, coping is poorly understood in ALS.

METHODS

We examined 41 ALS patients using a standardised interview, a validated coping self-rating questionnaire and a self-rating depression scale. The evaluation was repeated after six months.

RESULTS

"Loss of speech", "loss of mobility" and "the poor prognosis" were the most frequent answers in the standardised interview to questions regarding the worst aspect of the disease. Pain was seldom mentioned. "Family members" were most helpful in coping with the disease, followed by "unspecific mechanisms" and "technical aids". None of our patients expressed a wish for assisted suicide. In comparison with other fatal diseases, patients with ALS had similar rankings in the coping mechanism of "rumination", but lower rankings in "search for social integration", "defence of fear", "search for information and communication". In contrast,* "search for hold in the religion" was of high importance for our ALS patients. In the follow-up examination the importance of "search for information and communication" increased.

CONCLUSION

The results emphasise the importance of "loss of speech" and the importance of the caring family as well as the availability of technical aids in ALS. Coping in ALS seems to be based mainly on "rumination" and *"hold in the religion", but the increasing importance of "search for information" indicates that the sustained offer of information is essential.

Future states: the axioms underlying prospective, future-oriented, health planning instruments

Proscriptive planning exercises are critical to and generally accepted as integral to health planning at varying scales. These require specific instruments designed to predict future actions on the basis of present knowledge. At the macro-level of health economics, for example, a number of future-oriented Quality of Life Instruments (QL) are commonly employed. At the level of individual decision making, on the other hand, Advance Directives (AD's) are advanced as a means by which healthy individuals can assure their wishes will be carried out if at some future point they are incapacitated. As proscriptive tools, both instrument classes appear to share an axiomatic set whose individual parts have not been rigorously considered. This paper attempts to first identify and then consider a set of five axioms underlying future oriented health planning instruments. These axioms are then critiqued using data from a pre-test survey designed specifically to address their assumptions. Results appear to challenge the validity of the axioms underlying the proscriptive planning instruments.

Life quality vs the 'quality of life': assumptions underlying prospective quality of life instruments in health care planning

Quality of Life is a broad construct used in health planning, health economics, and medical decision-making. It is also a term that has a long currency in social and sociological literatures. This paper considers the assumptions underlying prospective QL instruments in an historical and contemporary context. It argues that as a tool in health planning and in clinical decision making life quality as a measurement has its origins in the early eugenics literature and the social policies that derived from it in first North America, the primary focus of this paper, and later in Europe. Reference to narrative and social literatures, as well as those involving coping and adaptation, are then used to critique the assumptions underlying this class of QL instruments. It concludes that to the degree now current prospective instruments reflect a purely physical perspective of "disease burden" irrespective of social conditions they create a context that works against life quality, and in some cases, the continuance of persons with physical differences.

Psychological adjustment and coping in adults with prosthetic limbs

The potential mediating effects of different coping strategies on the adjustment to living with a prosthetic limb were investigated in 44 adult amputees. Participants completed a questionnaire inquiring about coping, pain, emotional well-being, demographics, and disability-related variables. The coping strategy adopted and the extent of the adjustment to the prosthetic limb varied with age, site of limb loss, and cause of amputation. Furthermore, coping style mediated the adjustment to wearing a prosthetic limb. The results are discussed in terms of future applications and research.