Resilience, Pain Interference, and Upper Limb Loss: Testing the Mediating Effects of Positive Emotion and Activity Restriction on Distress

Experiences of persons with lower limb amputation after prosthetic rehabilitation in Ghana: A qualitative inquiry

BACKGROUND

Lower limb amputations (LLAs) have long been associated with physical, social, and psychological consequences. Individuals with LLAs have challenges with mobility and often become isolated from their social networks. Disability rehabilitation technologies such as prosthetic devices are used to improve the mobility capabilities of lower limb amputees. To improve clinical outcomes, feedback from the prosthetic users is a key element to consider.

OBJECTIVES

The study sort to explore the experiences of lower-limb prosthetic users after prosthetic rehabilitation in a prosthetic and orthotic rehabilitation center in the Eastern Region of Ghana.

STUDY DESIGN

This study adopted an exploratory descriptive qualitative study design.

METHODS

A purposive sampling technique and semistructured interview guide was used to interview 17 participants by the first author. The social model of disability underpinned the study. Lower-limb prosthetic users (≥18 years) with unilateral LLA attending outpatient follow-up at a prosthetic and orthotic rehabilitation center were recruited. The interviews were audio recoded, transcribed verbatim, and analyzed using the procedure for thematic content analysis by Braun and Clarke (2013).

RESULTS

Participants reported injuries and tingling in their residual limb. Internal stigma resulting from negative comments and labeling from the public were reported. Prosthetic users experienced empathy and being treated as weaklings by their family/peers. Participants avoided relationships because of recurrent rejection, embarrassment, fear of sexual abuse, and exploitation. As a coping method, some participants chose to isolate themselves to avoid humiliation and public disgrace. Other coping mechanisms included watching television, listening to music, conversing with others, ignoring criticism, and having faith in God.

CONCLUSION

Participants' narrative in this study gave insight into the varied lived experiences on the individual level, family/peer level, and the coping mechanisms used. Challenges relating to discomfort from the prosthesis, internal stigma, relationship avoidance, and altered sexual life should be given much attention and used in implementing initiatives to improve clinical outcomes.

Management of Upper Limb Amputation Rehabilitation: Synopsis of the 2022 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for Acquired Amputation

ABSTRACT

Upper limb amputation can result in significant functional impairment necessitating a comprehensive rehabilitation approach throughout the continuum of care. In 2022, the Departments of Veteran Affairs and Defense completed an updated clinical practice guideline for the management of upper limb amputation rehabilitation. This practice guideline was developed by a workgroup of subject-matter experts from a variety of disciplines. Twelve key questions were developed by the workgroup using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) format to establish the scope of the literature review. Eighteen recommendations were developed through extensive review of the available literature and use of the Grading of Recommendations, Assessment, Development and Evaluation criteria. The strength of each recommendation was determined based on the quality of the research evidence and the additional domains of the Grading of Recommendations, Assessment, Development and Evaluation criteria. Of the 18 recommendations, 4 were found to have sufficient evidence to suggest for use of a particular rehabilitation management strategy. Thus, the 2022 Department of Veteran Affairs and Department of Defense clinical practice guideline provides updated, evidence-based information on the care and rehabilitation of persons with upper limb amputation. However, a significant lack of high-quality evidence in upper limb amputation rehabilitation limited evidence-based clinical guidance to assist healthcare providers in managing this population.

Physical Activity and Health of Koreans with Spinal Cord Injury during COVID-19

Objectives: The primary purpose of this study was to explore the mediating roles of resilience and physical activity (PA) levels on the subjective health of people with spinal cord injury(SCI) during the COVID-19 pandemic.Methods: A total of 201 Koreans with SCI completed a survey between February and April 2021. The questionnaire measured participants' PA levels before and during the COVID-19 pandemic, resilience, and subjective health assessment. The data were analyzed using SPSS, and PROCESS macro (Model 6) was used to determine the dual mediation effects. Results: PA levels before COVID-19 positively affected resilience and PA levels during COVID-19, and resilience positively affected PA levels during COVID-19 and subjective health. PA levels during COVID-19 had a positive influence on subjective health. Moreover, resilience and PA levels during COVID-19 were independent mediators of the relationship between PA levels before COVID-19 and subjective health. PA levels before COVID-19 indirectly affected subjective health through a dual-mediated pathway of resilience and PA levels during COVID-19. Conclusion: We suggest that it is necessary to promote regular PA for people with physical disabilities to enhance resilience, and thus, maintain a healthy life even during a public health crisis.

AAOS/Major Extremity Trauma and Rehabilitation Consortium Clinical Practice Guideline Summary for Evaluation of Psychosocial Factors Influencing Recovery From Orthopaedic Trauma

The Clinical Practice Guideline for Evaluation of Psychosocial Factors Influencing Recovery from Adult Orthopaedic Trauma is based on a systematic review of current scientific and clinical research. The purpose of this clinical practice guideline is to improve outcomes after adult orthopaedic trauma by evaluating, and addressing, the psychosocial factors that affect recovery. This guideline contains one recommendation to address eight psychosocial factors after military and civilian adult orthopaedic trauma that may influence clinical, functional, and quality of life recovery. Furthermore, it addresses additional factors that may be associated with greater biopsychosocial symptom intensity, limitations, and/or diminished health-related quality of life. However, this guideline did not evaluate effective treatment strategies for the treatment or prevention of psychosocial factors. This guideline cannot be fully extrapolated to the treatment of children or adolescents. In addition, the work group highlighted the need for additional research because studies of general traumatic injuries do not always generalize to specific orthopaedic populations.

Psychometric properties of the spinal cord injury-quality of life (SCI-QOL) Resilience item bank in a sample with spinal cord injury and chronic pain

PURPOSE

To describe the psychometric properties (e.g., data distribution characteristics, convergent/discriminant validity, internal consistency reliability, and test administration characteristics) of the spinal cord injury quality of life measurement system (SCI-QOL) Resilience item bank delivered as a computer adaptive test (CAT) in a sample of individuals with chronic pain and spinal cord injury (SCI).

METHODS

Descriptive statistics were calculated to investigate variable data distribution characteristics. Correlation analyses were conducted for convergent and discriminant validity. Item response theory-derived reliability was calculated for the SCI-QOL Resilience CAT.

RESULT

One hundred thirty-three adults with SCI (N = 133; 73.5% male, 26.5% female) were enrolled. Sample mean T score on the SCI-QOL Resilience measure was 48.40, SD = 8.60 (min = 29.4; max = 70.0). The CAT administered between 4 (most common, 41.4% of cases) and 12 (9% of cases) items with the Mean_#items = 5.73, SD = 2.45. The SCI-QOL Resilience CAT scores were normally distributed, with very low ceiling (0%) and floor (3%) effects. The SCI-QOL Resilience CAT had a reliability of 0.89, and the mean length of time for respondents to complete the SCI-QOL Resilience CAT was 44.34 s. SCI-QOL Resilience CAT validity was supported by significant moderate correlations with pain acceptance, depressive symptoms, pain catastrophizing, positive affect and well-being, and pain interference (convergent validity) and small non-significant correlations with age, sex, injury level, pain intensity, mobility level, and years since injury (discriminant validity).

CONCLUSION

The SCI-QOL Resilience CAT demonstrated good convergent and discriminant validity. The CAT administration characteristics were impressive: With few items (low response burden), the scale achieved good reliability.

Psychological resilience associates with pain experience in women treated for breast cancer

Background and aims Psychological resilience refers to successful adaptation or a positive outcome in the context of significant life adversity, such as chronic pain. On the other hand, anxiety closely associates with pain. The aim of this study was to explore how anxiety and psychological resilience together associate with persistent and experimental pain. Methods In a cross-sectional design, we studied 160 patients who had previously been treated for breast cancer and who now reported at least moderate pain (NRS ≥ 4) in any area of the body. Psychological resilience was measured on the Resilience Scale-14, anxiety on the Hospital Anxiety and Depression Scale, and intensity and interference of persistent pain by means of the Brief Pain Inventory. The cold pressor test was conducted to assess sensitivity to experimental cold pain. Results The results showed that resilience associated with pain interference in persistent pain, and that anxiety moderated this effect. Higher psychological resilience was associated with lower pain interference and this association was stronger in patients with low anxiety than among patients with high anxiety. These effects were visible with regard to persistent pain but not in experimental cold pain. Conclusions These results indicate that chronic pain and experimental pain as well as pain severity and pain interference are psychologically different phenomena. Psychological resilience protects against pain interference but effectively only in patients with low anxiety. It is necessary also to consider protective factors in addition to vulnerability factors in cases of persistent pain. Implications Resilience has been considered a potential target for intervention in chronic pain. However, high levels of anxiety might diminish the protective effect of psychological resilience in clinical settings. Therefore, it is important to treat anxiety in addition to resilience enhancing interventions. Patients with low psychological distress might be more suitable for resilience enhancing interventions than patients with high anxiety.

Qualitative analysis of resilience characteristics of people with unilateral transtibial amputation

BACKGROUND

Resilience characteristics are a significant factor in the highly variable rehabilitation outcomes for people in middle age or later with transtibial amputation.

OBJECTIVE

The purpose of this study was to describe resilience characteristics meaningful to people with transtibial amputation in middle age or later, who use a prosthesis.

METHODS

Semi-structured interviews were conducted, audio recorded, and transcribed with eighteen participants. Interview transcripts were coded and analyzed using a directed content analysis approach, guided by Charney's theory of resilience and Connor-Davidson Resilience Scale scores.

RESULTS

Five main resilience characteristics (themes) were identified: coping skills, cognitive flexibility, optimism, skill for facing fear, and social support. Participants with higher resilience scores generally described effective use of coping skills, cognitive flexibility, optimism, skills in facing fears, and social support to attain meaningful goals. In contrast, participants with lower resilience scores discussed passive coping strategies, cognitive rigidity, general pessimism, avoidance of activities due to fear, or social support limitations.

CONCLUSION

Coping skills, cognitive flexibility, optimism, skills for facing fear, and social support were identified as meaningful resilience characteristics for people with transtibial amputation in middle age or later. These characteristics can be targeted and enhanced using resilience interventions. Future research should consider these characteristics when designing and testing rehabilitation focused resilience interventions for people with TTA.

Risk of depression following traumatic limb amputation—a general population-based cohort study

Background: Individuals with traumatic limb amputation (TLA) may be at risk of depression, but evidence of increased depression after TLA from longitudinal studies has been limited. It is also unknown whether physical function, cognitive function, and employment prior to amputation affects depression risk. We aimed to examine longitudinal associations between TLA and depression in working age men, and to explore the role of pre-amputation occupational and individual characteristics. Methods: A Swedish national register-based cohort of 189,220 men born between 1952 and 1956, and who attended conscription assessments in adolescence, was followed from 1985 to 2009. Physical, cognitive, and psychological characteristics were measured at the conscription examination, and occupational information was obtained from the 1985 census. Main outcome measures were hospital inpatient and outpatient admissions for depression. Results: In total, 401 men underwent TLA; mean age at amputation was 42.5 years (SD 7.4). Cox regression produced an unadjusted hazard ratio (95% confidence interval) of 2.61 (1.62–4.21) for risk of subsequent depression associated with TLA compared with the general population. Adjustment for occupational, physical, cognitive, and psychological characteristics did not change the association much, producing a hazard ratio of 2.53 (1.57–4.08). Conclusions: TLA is associated with an increased risk of depression in men over more than two decades of follow up. Occupational and individual characteristics prior to amputation did not greatly change depression risk following amputation. We speculate that a coordinated combination of social support and medical management may help reduce persistent depression risk in men who experience amputation.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Positive factors, pain, and function in adults with multiple sclerosis

OBJECTIVE

Much is known about the associations between negative factors and adjustment to chronic pain. However, less is known about how positive factors (e.g., positive affect [PA], resilience) function in relation to disability and mood in individuals with multiple sclerosis (MS). To better understand how positive factors contribute to function we sought to determine if (a) PA and/or trait resilience moderate the associations between pain intensity and function (pain interference, depressive symptoms), and (b) trait resilience concurrently mediates the association between PA and function in a sample of individuals with MS.

METHOD

There were 455 adults with MS who provided data via an ongoing survey.

RESULTS

Controlling for negative affect, demographic, and disease-related variables, cross-sectional path analysis revealed the following: PA and trait resilience did not moderate the associations between pain intensity and pain interference (βPA = 0.01, p = .86; βRESILIENCE = 0.04, p = .33), and pain intensity and depression (βPA = 0.01, p = .79; βRESILIENCE = -0.02, p = .60). However, trait resilience significantly mediated the associations between PA and both criterion variables (abINTERFERENCE = -0.03, p = .03; abDEPRESSION = -0.13, p < .001).

CONCLUSIONS

The findings provide preliminary support for the conclusion that PA is indirectly related to pain interference and depression via resilience, rather than serves as a protective function. The findings are consistent with theoretical models suggesting that increases in PA build personal resources. Research examining the potential benefits of increasing PA and resilience to improve pain outcomes in individuals with MS is warranted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Cognitive and affective mechanisms of pain and fatigue in multiple sclerosis

OBJECTIVE

To examine the extent to which pain catastrophizing, fatigue catastrophizing, positive affect, and negative affect simultaneously mediated the associations between common symptoms of multiple sclerosis (MS; i.e., pain, fatigue) and impact on daily life, depressive symptoms, and resilience.

METHOD

Participants were community-dwelling adults with MS (N = 163) reporting chronic pain, fatigue, and/or moderate depressive symptoms. Multiple mediation path analysis was used to model potential mediators of pain and fatigue separately, using baseline data from a randomized controlled trial comparing two symptom self-management interventions.

RESULTS

In the pain model, pain catastrophizing was a mediator of pain intensity with pain interference and depression. Negative affect was a mediator of pain intensity with depression and resilience. In the fatigue model, fatigue catastrophizing was a mediator of fatigue intensity with fatigue impact and depression. Positive affect was a mediator of fatigue intensity with depression and resilience.

CONCLUSIONS

These findings provide preliminary support for the presence of differential effects of cognitive-affective mediators and suggest potential targets for psychological interventions based on an individual's clinical presentation. The differential mediating effects also support the inclusion of both positive and negative aspects of psychological health in models of pain and fatigue, which would not be otherwise apparent if negative constructs were examined in isolation. To our knowledge, this is the first study to utilize a multivariate path analysis approach to examine cognitive-affective mediators of pain and fatigue in MS, while also examining positive and negative constructs concurrently. (PsycINFO Database Record

Resilience and positive affect contribute to lower cancer-related fatigue among Chinese patients with gastric cancer

AIMS AND OBJECTIVES

To investigate the prevalence of cancer-related fatigue and explore the relationship between resilience, positive affect, and fatigue among Chinese patients with gastric cancer.

BACKGROUND

Cancer-related fatigue is the most distressing symptom reported frequently by cancer patients during both treatment and survival phases. Resilience and positive affect as vital protective factors against cancer-related fatigue have been examined, but the underlying psychological mechanisms are not well understood.

DESIGN

A cross-sectional study.

METHODS

Two hundred and three gastric cancer patients were enrolled from three hospitals in China. The Cancer Fatigue Scale, the positive affect subscale of the Positive and Negative Affect Schedule and the Connor-Davidson Resilience Scale (CD-RISC10) were administered. Hierarchical linear regression modelling was conducted to examine the association between resilience and cancer-related fatigue, and the mediating effect of positive affect.

RESULTS

The incidence of clinically relevant fatigue among patients with gastric cancer was 91.6%. Regression analysis showed that resilience was negatively associated with cancer-related fatigue, explaining 15.4% of variance in cancer-related fatigue. Mediation analysis showed that high resilience was associated with increased positive affect, which was associated with decreased cancer-related fatigue.

CONCLUSIONS

Cancer-related fatigue is prevalent among patients with gastric cancer. Positive affect may mediate the relationship between resilience and cancer-related fatigue.

RELEVANCE TO CLINICAL PRACTICE

Interventions that attend to resilience training and promotion of positive affect may be the focus for future clinical and research endeavours.

Leading the Way to Solutions to the Opioid Epidemic: AOA Critical Issues

BACKGROUND

In the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion.

METHODS

The literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), the impact of strategies on bone and soft-tissue healing, and pain relief are summarized as they relate to the management of orthopaedic injuries and conditions. Additionally, a section on designing solutions to address the current opioid crisis is presented.

RESULTS

The mechanism of action of different classes of analgesic medications is discussed, as well as the basic scientific evidence regarding the impact of narcotic and nonnarcotic analgesic medications on bone-healing and on other organ systems. Differences between pain and nociception, various treatment strategies, and clinical comparisons of the effectiveness of various analgesics compared with opioids are summarized. Finally, options for addressing the opioid crisis, including the description of a large system-wide intervention to impact prescriber behavior at the point of care using health-information solutions, are presented.

CONCLUSIONS

Orthopaedic leaders, armed with information and strategies, can help lead the way to solutions to the opioid epidemic in their respective communities, institutions, and subspecialty societies. Through leadership and education, orthopaedic surgeons can help shape the solution for this critical public health issue.

Changes in Resilience Predict Function in Adults With Physical Disabilities: A Longitudinal Study

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 (F1,885=70.23; P<.001; R2=.54) and fatigue (F1,885=25.66; P<.001; R2=.64), and an increase in resilience was associated with improved sleep quality (F1,885=30.76; P<.001; R2=.48) and physical function (F1,885=16.90; P<.001; R2=.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.

Resilience and Traumatic Brain Injury Among Iraq/Afghanistan War Veterans: Differential Patterns of Adjustment and Quality of Life

OBJECTIVE

We examined the degree to which a resilient personality prototype predicted adjustment among war Veterans with and without a traumatic brain injury (TBI) while covarying the level of combat exposure.

METHOD

A total of 127 war Veterans (107 men, 20 women; average age = 37 years) participated. Personality prototypes were derived from the Multidimensional Personality Questionnaire (Patrick, Curtain, & Tellegen, 2002). Measures were administered at baseline, and a subset was administered at 4- and 8-month follow-ups.

RESULTS

Veterans with resilient personalities reported less sleep disturbance, more health-promoting behaviors, psychological flexibility, and emotional distress tolerance than Veterans with undercontrolled or overcontrolled prototypes. Path models revealed that resilience significantly predicted posttraumatic stress disorder (PTSD), depression, quality of life, and social support over time. TBI had unique and consistent effects only on PTSD.

CONCLUSION

Personality characteristics influence distress and quality of life among war Veterans with and without TBI. Implications for assessment, interventions, and research are discussed.