Anxiety, pain catastrophizing, and pain outcomes among older adults with chronic orofacial pain

Although chronic orofacial pain (COFP) is common among older adults, the role of psychological factors in pain outcomes among this population has received limited attention. This study examined the role of anxiety and pain catastrophizing, two corelates of pain in other populations, in pain intensity and interference among 166 older adults with COFP (79% female, Mage = 68.84, SD = 5.56). Participants completed an online survey including measures of anxiety, pain catastrophizing, and pain intensity/interference. We applied mediation analyses to test indirect associations between anxiety and pain outcomes via pain catastrophizing. Results indicated that anxiety was positively associated with pain intensity and pain interference (bs = .70-1.12, ps < .05). There was also an indirect association between anxiety and pain interference through pain catastrophizing (b = .35, 95% CI [.0383, .7954]), indicating pain catastrophizing partially accounts for this relationship. Assessing and addressing anxiety and pain catastrophizing has the potential to improve treatment outcomes in this population.

Minimal clinically important difference in the World Health Organization Quality of Life Brief (WHOQOL-BREF) for adults with neurofibromatosis

PURPOSE

This study aimed to estimate minimal clinically important difference (MCID) values for the World Health Organization Quality of Life Brief version (WHOQOL-BREF) among adults with neurofibromatosis (NF). An MCID is needed to demonstrate clinical meaningfulness of interventions for NF.

METHODS

We estimated MCID for the WHOQOL-BREF: the quality of life (QoL) measure recommended by the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration. We used data from 228 clinical trial participants with NF type 1, NF type 2-related schwannomatosis, or schwannomatosis (SCHWN) who completed 10 weeks of a virtual group mind-body program targeting resiliency or a time- and attention-matched control. Following established guidelines, we estimated MCIDs using both anchor-based and distribution-based methods for physical, psychological, social relationships, and environmental domains of the WHOQOL-BREF.

RESULTS

MCID results varied across method and QoL domain. Three anchor-based methods, average change (AC), change difference (CD), and regression (REG), yielded the most consistent and comparable MCID across QoL domains. Based on these methods, we recommend ranges for each QoL domain: Physical QoL (3.9-7.3), Psychological QoL (4.7-8.1), Social QoL (2.6-5.9), and Environmental QoL (4.1-6.6).

CONCLUSION

Establishing a rigorous MCID for QoL in NF is a critical step toward evaluating meaningful change in response to psychosocial interventions.

Psychosocial Distress Among Certified Nursing Assistants in Long-Term Care During the COVID-19 Pandemic: A Social Ecological Model Informed Scoping Review

OBJECTIVES

This scoping review maps the literature on psychosocial distress and coping among nursing assistants (CNAs) in long-term care facilities (LTC) during the COVID-19 pandemic onto the Social Ecological Model (SEM) of Occupational Stress.

METHODS

Searches yielded 862 unique studies. Inclusion criteria were sample CNAs or equivalent in LTC; includes psychosocial variable; and collect data from February 2020-. A multi-phasic, meta-synthesis was used to synthesize qualitative data.

RESULTS

We identified 20 studies (13 quantitative, 7 qualitative) conducted between March 2020 and December 2021 from 14 countries. Prevalence rates were reported for perceived stress (31-33%; n = 1 study), post-traumatic stress (42%; n = 1), anxiety (53%; n = 1), depression (15-59%; n = 2), suicidal thoughts (11-15%; n = 1), and everyday emotional burnout (28%; n = 1). Qualitative studies identified factors contributing to psychosocial distress and coping at each SEM level (i.e. individual, microsystem, organization, and peri-/extra-organizational). Quantitative studies primarily measured factors relating to psychosocial distress and coping at the individual and organizational levels.

CONCLUSIONS & CLINICAL IMPLICATIONS

This review identifies specific targets for intervention for psychosocial distress among CNAs in LTC at multiple levels, including job clarity; workload; facility culture; community relations; and policy. These intervention targets remain relevant to the LTC industry beyond the context of the COVID-19 pandemic.

Advancing Methodological Rigor for Psychosocial Aspects of Neuropalliative Care Interventions

Background: Neurological disorders (NDs) have unique biopsychosocial-spiritual features that impact patients and their families. As a result, the subspeciality of neuropalliative care (NPC) emerged within the past decade and has grown exponentially in research and practice. Given the cognitive, emotional, and behavioral changes associated with NDs, psychosocial components (eg, coping skills) of NPC interventions are essential for improving the quality of life for patients and families. However, psychosocial components of NPC interventions warrant more rigorous testing to improve their evidence base and their likelihood of implementation and dissemination. Aim: In this commentary, we provide methodological recommendations with the goal of improving scientific knowledge and rigor for psychosocial components of multicomponent NPC interventions in clinical trials. Results: We emphasize the need for transparent reporting of psychosocial intervention components; using established models of intervention development to guide the development and testing of multicomponent NPC interventions; identifying mechanisms of action for psychosocial outcomes; and choosing psychometrically sound measures for mechanisms and outcomes. Conclusions: Given the importance of psychosocial care to the holistic NPC model, rigorous testing of psychosocial components of NPC interventions is a high priority for clinical investigators to advance the evidence base and practice of NPC.

Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Thematic Analysis of Psychosocial Stressors and Adaptive Coping Strategies Among Informal Caregivers of Patients Surviving ICU Admission for Coma

BACKGROUND

Family caregivers of patients with severe acute brain injury (SABI) admitted to intensive care units (ICUs) with coma experience heightened emotional distress stemming from simultaneous stressors. Stress and coping frameworks can inform psychosocial intervention development by elucidating common challenges and ways of navigating such experiences but have yet to be employed with this population. The present study therefore sought to use a stress and coping framework to characterize the stressors and coping behaviors of family caregivers of patients with SABI hospitalized in ICUs and recovering after coma.

METHODS

Our qualitative study recruited a convenience sample from 14 US neuroscience ICUs. Participants were family caregivers of patients who were admitted with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, traumatic brain injury, or hypoxic-ischemic encephalopathy; had experienced a comatose state for > 24 h; and completed or were scheduled for tracheostomy and/or gastrostomy tube placement. Participants were recruited < 7 days after transfer out of the neuroscience ICU. We conducted live online video interviews from May 2021 to January 2022. One semistructured interview per participant was recorded and subsequently transcribed. Recruitment was stopped when thematic saturation was reached. We deductively derived two domains using a stress and coping framework to guide thematic analysis. Within each domain, we inductively derived themes to comprehensively characterize caregivers' experiences.

RESULTS

We interviewed 30 caregivers. We identified 18 themes within the two theory-driven domains, including ten themes describing practical, social, and emotional stressors experienced by caregivers and eight themes describing the psychological and behavioral coping strategies that caregivers attempted to enact. Nearly all caregivers described using avoidance or distraction as an initial coping strategy to manage overwhelming emotions. Caregivers also expressed awareness of more adaptive strategies (e.g., cultivation of positive emotions, acceptance, self-education, and soliciting social and medical support) but had challenges employing them because of their heightened emotional distress.

CONCLUSIONS

In response to substantial stressors, family caregivers of patients with SABI attempted to enact various psychological and behavioral coping strategies. They described avoidance and distraction as less helpful than other coping strategies but had difficulty engaging in alternative strategies because of their emotional distress. These findings can directly inform the development of additional resources to mitigate the long-term impact of acute psychological distress among this caregiver population.

Diverse learners: learning disabilities and quality of life following mind-body and health education interventions for adults with neurofibromatosis

PURPOSE

Neurofibromatosis (NF) is associated with low quality-of-life (QoL). Learning disabilities are prevalent among those with NF, further worsening QoL and potentially impacting benefits from mind-body and educational interventions, yet research on this population is scarce. Here, we address this gap by comparing NF patients with and without learning disabilities on QoL at baseline and QoL-related gains following two interventions.

METHODS

Secondary analysis of a fully-powered RCT of a mind-body program (Relaxation Response Resiliency Program for NF; 3RP-NF) versus an educational program (Health Enhancement Program for NF; HEP-NF) among 228 adults with NF. Participants reported QoL in four domains (Physical Health, Psychological, Social Relationships, and Environmental). We compare data at baseline, post-treatment, and 12-month follow-up, controlling for intervention type.

RESULTS

At baseline, individuals with NF and learning disabilities had lower Psychological (T = -3.0, p = .001) and Environmental (T = -3.8, p < .001) QoL compared to those without learning disabilities. Both programs significantly improved all QoL domains (ps < .0001-0.002) from baseline to post-treatment, regardless of learning disability status. However, those with learning disabilities exceeded the minimal clinically important difference in only one domain (Psychological QoL) compared to three domains in individuals without learning disabilities. Moreover, those with learning disabilities failed to sustain statistically significant gains in Psychological QoL at 12-months, while those without learning disabilities sustained all gains.

CONCLUSION

Adults with NF and learning disabilities have lower Psychological and Environmental QoL. While interventions show promise in improving QoL regardless of learning disabilities, additional measures may bolster clinical benefit and sustainability among those with learning disabilities.

Culturally Adapting Mind-Body Interventions for Black Individuals with Chronic Pain: Arguments and Recommendations Towards a Task-Sharing Approach

Compared to non-Hispanic White individuals, non-Hispanic Black Individuals report worse chronic pain from a variety of medical issues. Among the options for non-pharmacological pain treatment, mind-body interventions (MBI) are a promising modality to help Black individuals manage their chronic pain effectively. MBIs such as mindfulness meditation improve chronic pain and chronic pain-related outcomes by shifting the individual's perception of pain away from stress-related cognitive appraisals, emotional reactions, and behaviors. MBIs may also address disparities in chronic pain outcomes between Black and White individuals because of their contextual overlap with (1) centering and contemplative prayer, (2) racial empowerment, and (3) social support. Despite this overlap, the demand for MBIs among Black individuals has generally been low due to lingering access and acceptability barriers. To reduce these barriers for Black individuals with chronic pain, we must adopt a community-engaged approach and culturally adapt MBIs for the specific historic, environmental, financial, and psychosocial needs of Black individuals. Example adaptations include increasing Black representation among MBI instructors, reducing geographical access barriers, accommodating the financial and personal realities of Black adults, and explicitly allowing relevant attitudes, practices, and terms.

Emotional distress, social support, and functional dependence predict readiness for hospital discharge in a prospective sample of cognitively intact cardiac arrest survivors

AIM

To inform screening, referral and treatment initiatives, we tested the hypothesis that emotional distress, social support, functional dependence, and cognitive impairment within 72 hours prior to discharge predict readiness for discharge in awake and alert cardiac arrest (CA) survivors.

METHODS

This was a secondary analysis of a prospective single-center cohort of CA survivors enrolled between 4/2021 and 9/2022. We quantified emotional distress using the Posttraumatic Stress Disorder Checklist-5 and PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a; perceived social support using the ENRICHD Social Support Inventory; functional dependence using the modified Rankin Scale; and cognitive impairment using the Telephone Interview for Cognitive Status. Our primary outcome was readiness for discharge, measured using the Readiness for Hospital Discharge Scale. We used multivariable linear regression to test the independent association of each survivorship factor and readiness for discharge.

RESULTS

We included 110 patients (64% male, 88% white, mean age 59 [standard deviation ± 13.1 years]). Emotional distress, functional dependence, and social support were independently associated with readiness for discharge (adjusted β's [absolute value]: 0.25-0.30, all p < 0.05).

CONCLUSIONS

Hospital systems should consider implementing routine in-hospital screening for emotional distress, social support, and functional dependence for CA survivors who are awake, alert and approaching hospital discharge, and prioritize brief in hospital treatment or post-discharge referrals.

Exploring mechanisms of improvement in the Active Brains intervention for older adults with chronic pain and early cognitive decline

OBJECTIVES

We iteratively developed, optimized, and established the feasibility of a virtual, group-based, mind-body activity program (Active Brains, AB), supported by Fitbit for older adults with chronic pain (CP) and early cognitive decline (ECD). Guided by the principles of the NIH stage model we 1) explore signals of improvement in AB outcomes and hypothesized mechanisms of action and 2) explore relationships between changes in outcomes with changes in mechanisms.

METHODS

Participants were N = 15 older adults (age ≥ 60) with CP-ECD from two NIH stage 1 pilot studies of AB. We conducted paired t-tests to explore pre-post improvements, and correlations to investigate associations between changes in outcomes and mechanisms.

RESULTS

We observed small to large improvements across co-primary and secondary outcomes (d = 0.24-1.09). We observed small to medium improvements in 4 out of 5 hypothesized mechanisms (d = 0.23-0.47). Overall, improvements in outcomes had moderate to large associations with improvements in hypothesized mechanisms.

CONCLUSION

AB was associated with improvements across several co-primary and secondary outcomes, and hypothesized mechanisms. Pain-specific coping and general coping skills are promising treatment targets to address the CP-ECD comorbidity among older adults.

Breaking the Disability Spiral: A Case Series Report Illustrating the Delivery of a Brief Skills Based Coaching Intervention to Prevent Chronic Dysfunction and Pain After Orthopedic Injury

Orthopedic traumas are common, costly, and burdensome - particularly for patients who transition from acute to chronic pain. Psychosocial factors, such as pain catastrophizing and pain anxiety, increase risk for poor outcomes after injury. The Toolkit for Optimal Recovery (TOR) is a novel multi-component mind-body intervention informed by the fear-avoidance model to promote re-engagement in daily activities and prevent transition toward chronic pain and physical dysfunction. The current case series aims to 1) describe the intervention and 2) showcase the treatment course of three TOR completers from diverse geographic locations in the U.S. with distinct injury types and varying personal identities to illustrate how the intervention can be delivered flexibly. Results indicate pre-to-post program improvement in physical function, pain severity, pain catastrophizing, pain anxiety, and other relevant outcomes targeted by the intervention (i.e., depression, mindfulness, coping). Experiences of our three TOR completers suggest that integrating TOR with standard orthopedic care may promote physical recovery after injury.

Improving multimodal physical function in adults with heterogeneous chronic pain; Protocol for a multisite feasibility RCT

BACKGROUND

Chronic pain is associated with substantial impairment in physical function, which has been identified as a top concern among persons with pain. GetActive-Fitbit, a mind-body activity program, is feasible, acceptable, and associated with improvement in physical function among primarily White, sedentary individuals with pain. In preparation for a multisite efficacy trial, we must examine feasibility across multiple sites with diverse patient populations. Here we describe the protocol of a multisite, feasibility RCT comparing GetActive-Fitbit with a time- and attention-matched educational comparison (Healthy Living for Pain). We aim to 1) test multisite fidelity of clinician training; 2) evaluate multisite feasibility benchmarks, including recruitment of chronic pain patients taking <5000 steps/day and racial and ethnic minorities; and 3) optimize fidelity and study protocol in preparation for a future multisite efficacy trial.

METHODS

Clinician training fidelity was assessed via roleplays and mock group sessions. Feasibility (i.e., recruitment, acceptability, credibility, adherence, satisfaction), multimodal physical function (e.g., self-report, 6-Minute Walk Test, step-count), and other psychosocial outcomes are assessed at baseline, posttest, and 6 months. Protocol optimization will be assessed using exit interviews and cross-site meetings.

RESULTS

The trial is ongoing. Clinician training is complete. 87 participants have been recruited. 54 completed baseline assessments and randomization, 44 are mid-intervention, and 9 have completed the intervention and posttest.

CONCLUSIONS

This study addresses the critical need for feasible, acceptable mind-body-activity interventions for chronic pain that follow evidence-based guidelines and improve all aspects of physical function across diverse populations. Results will inform a future fully-powered multisite efficacy trial.

CLINICAL TRIAL REGISTRATION

NCT05700383.

Palliative Care Interventions for Persons With Neurodegenerative Disease: A Scoping Review of Clinical Trial Study Design Features

Background: Within palliative care research, best practice guidelines to conduct scientifically rigorous clinical trials for neurodegenerative diseases are underexplored. This patient population experiences unique challenges, including fluctuations in cognitive capacity, care partner (CP) and proxy involvement, and high adverse events (AEs), that necessitate special consideration when designing clinical trials. Objective: The objective of this study was to describe and identify clinical trial design features that have been documented in studies involving a neuropalliative intervention for persons with neurodegenerative diseases, highlighting features that have been adapted for this unique patient population. Design: We conducted a scoping review of clinical trials with a neuropalliative intervention for persons with neurodegenerative disease. We searched Cochrane, Web of Science, EMBASE, Scopus, and PubMed (MEDLINE) databases for articles published in English between 1950 and 2023. Two reviewers screened, extracted, and synthesized data from the included articles. A third reviewer adjudicated instances of conflict. The data were analyzed using a thematic framework approach. Results: Of 1025 texts, 44 articles were included. Seven study design features were analyzed: (1) consent, (2) proxies and CPs, (3) recruitment strategies, (4) retention strategies, (5) choice of comparator, (6) AEs, and (7) internal validity. This scoping review found disparities in study design features around structured consent, proxies and CPs, comparators, and AEs. Conclusions: To date, neuropalliative care clinical trials have had varied study designs and the majority of research has focused on dementia. Research guideline development for high-quality neuropalliative care clinical trials is greatly needed across the range of neurodegenerative diseases. To increase the scientific rigor of clinical trials and neuropalliative care, we recommend a standardized capacity assessment for consent, defining conditions for the CP, proxy, and AEs, systematizing appropriate comparators, and outlining preemptive recruitment and retention strategies to address the broader unpredictable challenges of palliative care research.

"I Wish I Had That!": A Qualitative Analysis of Psychosocial Treatment Preferences Among Young Adults With Recent Concussion and Anxiety

OBJECTIVE

To assess psychosocial treatment preferences and factors that may affect treatment participation among young adults with a recent concussion and co-occurring anxiety.

DESIGN

In-depth, semi-structured individual qualitative interviews, followed by thematic analysis using a hybrid deductive-inductive approach.

SETTING

Academic medical center in the US Northeast.

PARTICIPANTS

Seventeen young adults (18-24y) who sustained a concussion within the past 3-10 weeks and reported at least mild anxiety (≥5 on the Generalized Anxiety Disorder-7 questionnaire).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Primary outcomes include preferences for program content (eg, topics and skills), delivery modality, format, and barriers and facilitators to participation.

RESULTS

We identified 4 domains characterizing participants' perceptions of and preferences for treatment. (1) Program content: Participants preferred a program early after injury that included psychoeducation and coping skills (eg, activity pacing, deep breathing, mindfulness). (2) Therapeutic processes: Participants preferred a person-centered approach in which clinicians normalized anxiety postconcussion and reassured them of recovery. (3) Program logistics: Participants endorsed that a brief, virtual program would be acceptable. They preferred access to program components through multiple modalities (eg, audio, video) and accommodations to manage concussion symptoms. (4) Barriers and facilitators to participation: Barriers included acute concussion symptoms (eg, screen sensitivity), time constraints, and forgetting sessions. Facilitators included a program that is flexible (format, scheduling), personalized (self-chosen mode for reminders, measure of accountability), and accessible (ie, advertising through health care professionals or social media).

CONCLUSIONS

Participants need psychosocial support that normalizes their experiences and provides education and coping tools. Treatments should be accessible, flexible, and person centered. Psychosocial treatments meeting these preferences may help optimize the recovery of young adults with recent concussion and anxiety.

"I completely shut down": A mixed methods evaluation of the fear-avoidance model for young adults with a recent concussion and anxiety

PURPOSE/OBJECTIVES

The fear-avoidance model is a well-established framework for understanding the transition from acute to chronic pain. However, its applicability to concussions is not yet well understood. Here, we conduct the first mixed methods analysis of the fear-avoidance model in young adults with a recent concussion and co-occurring anxiety and assess the model's alignment with their lived experience.

RESEARCH METHOD/DESIGN

We conducted a mixed methods analysis using a cross-sectional parallel design. Seventeen participants completed questionnaires corresponding with the elements in the fear-avoidance model (e.g., pain catastrophizing, avoidance, disability, anxiety, depression, etc.) and participated in semistructured interviews probing their experiences following their concussion between March 2021 and February 2022. We calculated bivariate correlations for quantitative data and analyzed the qualitative data using hybrid inductive-deductive thematic analysis.

RESULTS

Quantitative results demonstrated strong and medium-sized correlations among theorized relationships within the fear-avoidance model (rs = .40-.85) with the majority being statistically significant. Qualitative results provided substantial convergent and complementary support (e.g., bi-directionality of some relationships, associations between nonadjacent model components, centrality of anxiety in symptom persistence) for the application of the fear-avoidance model to concussions. Findings highlighted additional factors (social factors and post-injury endurance patterns) relevant to this population.

CONCLUSION/IMPLICATIONS

The fear-avoidance model is a useful lens for understanding the lived experience of young adults with a recent concussion and co-occurring anxiety. Psychosocial treatment for this population would benefit from focusing on the interplay of concussion symptoms, anxiety, depression, disability, and pain-related fear, offering adaptive confrontation strategies, and addressing the interpersonal impact of concussion. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The impact of a virtual mind-body program on symptoms of depression and anxiety among international English-speaking adults with neurofibromatosis

The neurofibromatoses (NFs) are a set of incurable genetic disorders that predispose individuals to nervous system tumors. Although many patients experience anxiety and depression, there is little research on psychosocial interventions in this population. The present study examined the effects of a mind-body intervention on depression and anxiety in adults with NF. This is a secondary analysis of the Relaxation Response Resiliency Program for NF (3RP-NF), an 8-week virtual group intervention that teaches mind-body skills (e.g., relaxation, mindfulness) to improve quality of life. Participants were randomized to 3RP-NF or the Health Enhancement Program for NF (HEP-NF) consisting of health informational sessions and discussion. We evaluated depression (PHQ-9) and anxiety (GAD-7) at posttreatment, 6 months, and 12 months. Both groups improved in depression and anxiety between baseline and posttest, 6 months, and 12 months. The 3RP-NF group showed greater improvements in depression scores from baseline to 6 months compared with HEP-NF and with lower rates of clinically significant depressive symptoms. There were no between-group differences for anxiety. Both interventions reduced distress and anxiety symptoms for individuals with NF. The 3RP-NF group may be better at sustaining these improvements. Given the rare nature of NF, group connection may facilitate reduced distress.

Mindfulness, coping, and optimism as mechanisms of change in the 3RP-NF intervention

INTRODUCTION

Neurofibromatosis (NF) is chronic neurogenetic condition that increases risk for poor quality of life, depression, and anxiety. Given the lack of biomedical treatments, we developed the "Relaxation Response Resiliency for NF" (3RP-NF) program to improve psychosocial outcomes among adults with NF.

OBJECTIVE

To move toward effectiveness testing, we must understand mechanisms that explained treatment effects. We tested whether our hypothesized mechanisms of change-mindfulness, coping, and optimism-mediated improvements in quality of life, depression, and anxiety among adults in the 3RP-NF program (N = 114; ages 18-70; 72.80% female; 81.58% White).

METHODS

We conducted mixed-effects models to assess whether these mechanisms uniquely mediated outcomes.

RESULTS

Improvements in quality of life were most explained by coping, (b = 0.97, SE = 0.28, CI [0.45, 1.56]), followed by mindfulness (b = 0.46, SE = 0.17, CI [0.15, 0.82]) and optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]). Improvements in depression and anxiety were most explained by mindfulness (b = -1.52, SE = 0.38, CI [-2.32, -0.85], CSIE = -0.26; b = -1.29, SE = 0.35, CI [-2.04, -0.67], CSIE = -0.23), followed by optimism (b = 0.39, SE = 0.12, CI [0.17, 0.65]; b = -0.49, SE = 0.20, CI [-0.91, -0.13]), but were not explained by coping (b = 0.22, SE = 0.43, CI [-0.62, 1.07]; b = 0.06, SE = 0.46, CI [-0.84, 0.97]), respectively.

CONCLUSIONS

Targeting mindfulness, coping, and optimism in psychosocial interventions may be a promising way to improve the lives of adults with NF.

Depression Negatively Impacts Dyadic Quality of Life Following Neuro-ICU Admission: A Prospective Study of Cognitively Intact Patients and Caregivers

BACKGROUND

Admission to a neurological intensive care unit (Neuro-ICU) can increase risk for depressive and anxiety symptoms for both patients and caregivers. To better understand the long-term mental health impact of a Neuro-ICU admission, we examined the dyadic interdependence between depression and anxiety at Neuro-ICU admission with 3-month quality of life (QoL) for patients and caregivers in a longitudinal, observational cohort study.

METHOD

We assessed depressive and anxiety symptoms (Hospital Anxiety and Depression Scale; HADS) reported by neurologically intact patients (n = 72) and their caregivers (n = 72) within 2 weeks of Neuro-ICU admission (baseline) and 3-months post-discharge (follow-up). We examined the longitudinal association between dyadic depression and anxiety at Neuro-ICU admission and 3-month QoL (World Health Organization; QOL-BREF) across four domains (Physical, Psychological, Social relationships, and Environmental QoL) in separate actor-partner interdependence models (APIM) for patients and caregivers.

RESULTS

In the overall models, patients' own baseline depression levels were negatively associated with their own 3-month QoL in all domains (β =  - 0.53 to - 0.64, p < 0.001), and for caregivers, only in the psychological (β =  - 0.73, p < .001) and social relationships (β =  - 0.56, p < .001) domains. No actor effects were found for one's own baseline anxiety impacting one's own 3-month QoL. Partner effects for one's own depression were significant for caregivers on patients' 3-month psychological (β =  - 0.26, p < .02) and environmental (β =  - 0.29, p < .03) QoL, as well as for patients on caregiver's 3-month psychological QoL (β = 0.25, p < .02). No partner effects were significant in association with baseline anxiety and 3-month QoL in both patients and caregivers.

CONCLUSION

Neuro-ICU patients' and caregivers' baseline depression has significant negative impacts on their own long-term QoL. Caregivers demonstrate significant negative impacts on patient long-term QoL in domains related to emotional distress and caregiver burden. Early identification of mental health symptoms, especially depression, during Neuro-ICU admission may provide an intervention opportunity to improve QoL post-discharge for both dyad members.

Perspectives of adults with neurofibromatosis regarding the design of psychosocial trials: Results from an anonymous online survey

BACKGROUND/AIMS

Individuals with neurofibromatosis, including neurofibromatosis 1 (NF1), neurofibromatosis 2 (NF2)-related schwannomatosis (SWN), and other forms of SWN, often experience disease manifestations and mental health difficulties for which psychosocial interventions may help. An anonymous online survey of adults with neurofibromatosis assessed their physical, social, and emotional well-being and preferences about psychosocial interventions to inform clinical trial design.

METHODS

Neurofibromatosis clinical researchers and patient representatives from the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration developed the survey. Eligibility criteria included age ≥ 18 years, self-reported diagnosis of NF1, NF2, or SWN, and ability to read and understand English. The online survey was distributed internationally by the Neurofibromatosis Registry and other neurofibromatosis foundations from June to August 2020.

RESULTS

Surveys were completed by 630 adults (18-81 years of age; M = 45.5) with NF1 (78%), NF2 (14%), and SWN (8%) who were mostly White, not Hispanic/Latino, female, and from the United States. The majority (91%) reported that their neurofibromatosis symptoms had at least some impact on daily life. In the total sample, 51% endorsed a mental health diagnosis, and 27% without a diagnosis believed they had an undiagnosed mental health condition. Participants indicated that neurofibromatosis affected their emotional (44%), physical (38%), and social (35%) functioning to a high degree. Few reported ever having participated in a drug (6%) or psychosocial (7%) clinical trial, yet 68% reported they "probably" or "definitely" would want to participate in a psychosocial trial if it targeted a relevant concern. Top treatment targets were anxiety, healthier lifestyle, and daily stress. Top barriers to participating in psychosocial trials were distance to clinic, costs, and time commitment. Respondents preferred interventions delivered by clinicians via individual sessions or a combination of group and individual sessions, with limited in-person and mostly remote participation. There were no significant group differences by neurofibromatosis type in willingness to participate in psychosocial trials (p = 0.27). Regarding interest in intervention targets, adults with SWN were more likely to prefer psychosocial trials for pain support compared to those with NF1 (p < 0.001) and NF2 (p < 0.001).

CONCLUSION

This study conducted the largest survey assessing physical symptoms, mental health needs, and preferences for psychosocial trials in adults with neurofibromatosis. Results indicate a high prevalence of disease manifestations, psychosocial difficulties, and untreated mental health problems in adults with neurofibromatosis and a high degree of willingness to participate in psychosocial clinical trials. Patient preferences should be considered when designing and implementing psychosocial interventions to develop the most feasible and meaningful studies.

Does gender moderate resiliency variables and posttraumatic stress symptoms in informal caregivers of neurocritical care patients? An exploratory study

We examined gender differences between resiliency factors (i.e. mindfulness, self-efficacy, coping, intimate care, and caregiver preparedness) and posttraumatic stress symptoms (PTSS) in informal caregivers of patients in the neuroscience intensive care unit (Neuro-ICU). Ninety-two informal caregivers were enrolled during patients' hospitalization and completed resiliency measures at baseline, and a PTSS measure at baseline, 3 and 6 months. We conducted five ANCOVAs to explore gender and resiliency on PTSS. No significant main effects of gender on PTSS were observed across time points. However, main effects were seen for resiliency on PTSS at baseline for informal caregivers with high (vs. low) mindfulness, coping, and self-efficacy. Gender moderated the association between mindfulness and PTSS (i.e. high mindfulness at baseline was associated with lower PTSS in males compared to females at 3 months) and intimate care and PTSS (high intimate care at baseline was associated with lower PTSS in males than females at 6 months; high intimate care at baseline for females was associated with lower PTSS at 6 months than females with low intimate care). Overall, we observed associations among informal caregivers' gender, resiliency, and PTSS, with males particularly benefitting from mindfulness and intimate care. These findings hold value for future inquiry into gender differences in this population with possible clinical implications.

Improving Health for Older Adults With Pain Through Engagement: Protocol for Tailoring and Open Pilot Testing of a Mind-Body Activity Program Delivered Within Shared Medical Visits in an Underserved Community Clinic

BACKGROUND

Chronic musculoskeletal pain is prevalent and disabling among older adults in underserved communities. Psychosocial pain management is more effective than pharmacological treatment in older adults. However, underserved community clinics often lack psychosocial treatments, in part because of a lack of trained providers. Shared medical appointments, in which patients undergo brief medical evaluation, monitoring, counseling, and group support, are an efficacious and cost-effective method for chronic disease management in underserved clinics, reducing the need for specialized providers. However, shared medical visits are often ineffective for chronic pain, possibly owing to lack of inclusion of skills most relevant for older adults (eg, pacing to increase engagement in daily activities).

OBJECTIVE

We have described the protocol for the development and initial pilot effectiveness testing of the GetActive+ mind-body activity intervention for older adults with chronic pain. GetActive+ was adapted from GetActive, an evidence-based intervention that improved pain outcomes among mostly affluent White adults. We aim to establish the initial feasibility, acceptability, fidelity, and effectiveness of GetActive+ when delivered as part of shared medical appointments in a community clinic.

METHODS

We conducted qualitative focus groups and individual interviews with providers (n=25) and English-speaking older adults (aged ≥55 y; n=18) with chronic pain to understand the pain experience in this population, perceptions about intervention content, and barriers to and facilitators of intervention participation and implementation in this setting. Qualitative interviews with Spanish-speaking older adults are in progress and will inform a future open pilot of the intervention in Spanish. We are currently conducting an open pilot study with exit interviews in English (n=30 individuals in total). Primary outcomes are feasibility (≥75% of patients who are approached agree to participate), acceptability (≥75% of patients who enrolled complete 8 out of 10 sessions; qualitative), and fidelity (≥75% of session components are delivered as intended). Secondary outcomes include physical function-self-reported, performance based (6-minute walk test), and objective (step count)-and emotional function (depression and anxiety). Other assessments include putative mechanisms (eg, mindfulness and pain catastrophizing).

RESULTS

We began enrolling participants for the qualitative phase in November 2022 and the open pilot phase in May 2023. We completed the qualitative phase with providers and English-speaking patients, and the results are being analyzed using a hybrid, inductive-deductive approach. We conducted rapid analysis of these data to develop GetActive+ before the open pilot in English, including increasing readability and clarity of language, reducing the number of skills taught to increase time for individual check-ins and group participation, and increasing experiential exercises for skill uptake.

CONCLUSIONS

We provide a blueprint for the refinement of a mind-body activity intervention for older adults with chronic pain in underserved community clinics and for incorporation within shared medical visits. It will inform a future, fully powered, effectiveness-implementation trial of GetActive+ to help address the chronic pain epidemic among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05782231; https://clinicaltrials.gov/study/NCT05782231.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52117.

Bio-Experiential Technology to Support Persons With Dementia and Care Partners at Home (TEND): Protocol for an Intervention Development Study

BACKGROUND

Alzheimer disease and related dementias are debilitating and incurable diseases. Persons with dementia and their informal caregivers (ie, dyads) experience high rates of emotional distress and negative health outcomes. Several barriers prevent dyads from engaging in psychosocial care including cost, transportation, and a lack of treatments that target later stages of dementia and target the dyad together. Technologically informed treatment and serious gaming have been shown to be feasible and effective among persons living with dementia and their care partners. To increase access, there is a need for technologically informed psychosocial interventions which target the dyad, together in the home.

OBJECTIVE

This study aims to develop the toolkit for experiential well-being in dementia, a dyadic, "bio-experiential" intervention for persons with dementia and their caregivers. Per our conceptual model, the toolkit for experiential well-being in dementia platform aims to target sustained attention, positive emotions, and active engagement among dyads. In this paper, we outline the protocol and conceptual model for intervention development and partnership with design and development experts.

METHODS

We followed the National Institutes of Health (NIH) stage model (stage 1A) and supplemented the model with principles of user-centered design. The first step includes understanding user needs, goals, and strengths. We met this step by engaging in methodology and definition synthesis and conducting focus groups with dementia care providers (N=10) and persons with dementia and caregivers (N=11). Step 2 includes developing and refining the prototype. We will meet this step by engaging dyads in up to 20 iterations of platform β testing workshops. Step 3 includes observing user interactions with the prototype. We will meet this step by releasing the platform for feasibility testing.

RESULTS

Key takeaways from the focus groups include balancing individualization and the dyadic relationship and avoiding confusing stimuli. As of September 2023, we have completed focus groups with providers, persons with dementia, and their caregivers. Additionally, we have conducted 4 iterations of β testing workshops with dyads. Feedback from focus groups informed the β testing workshops; data have not yet been formally analyzed and will be reported in future publications.

CONCLUSIONS

Technological interventions, particularly "bio-experiential" technology, can be used in dementia care to support emotional health among persons with a diagnosis and caregivers. Here, we outline a collaborative intervention development process of bio-experiential technology through a research, design, and development partnership. Next, we are planning to test the platform's feasibility as well as its impact on clinical outcomes and mechanisms of action.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52799.

Resiliency outcomes after participation in an asynchronous web-based platform for adults with neurofibromatosis: The NF-Web study

The purpose of this study was to analyze secondary resiliency and user experience outcomes from a novel, 8-week website-based mind-body intervention (NF-Web) for adults (18+) with neurofibromatosis (NF1, NF2, and schwannomatosis), a genetic, neurocutaneous disorder characterized by nerve sheath tumors of the central and peripheral nervous system. The study design was a secondary data analysis of a single-arm, early feasibility pilot study (September 2020-May 2021) for adults with NF (N = 28). Across participants, the mean age was 46 (SD = 13.67) and included 22 females and 6 males. Participants completed baseline and posttest assessments (t-tests), as well as exit interviews (exploratory rapid data analysis). Results demonstrated that participation was associated with pre-to-post improvements in gratitude, coping, and mindfulness (p < .05). Exit interviews indicated participant enjoyment and that many would recommend NF-Web to a friend. Participants found the website easy to navigate and enjoyed NF-Web's video format. Many found transcripts useful if they had hearing differences or if English was their second language. NF-Web demonstrated initial signals of improvement in resiliency outcomes and positive user experience. Future pilot RCTs will explore these changes by NF type.

Palliative Care Clinical Trials in Underrepresented Ethnic and Racial Minorities: A Narrative Review

Introduction: A growing number of patients with serious illness who would benefit from palliative care are part of ethnoracial minority groups. Nevertheless, large disparities in provision of palliative services exist for minoritized populations. Furthermore, there is a relative dearth of palliative care research focused on minority groups and how best to provide high-quality, culturally tailored palliative care. The aim of this narrative review is to summarize the existing literature regarding palliative care clinical trials in underrepresented minority populations, describe methodological approaches, and provide guidance on future palliative care-focused clinical trials. Methods: We used the Scale for the Assessment of Narrative Review Articles (SANRA) and Cochrane's guidelines on conducting reviews. We used PubMed and Clinicaltrials.gov to review published, full-text articles or protocols (1950-2022), and limited to palliative care interventions focused on ethnoracial minority populations. We included randomized clinical trials (RCTs), including pilot and feasibility trials, protocols of RCTs, and studies that report RCT methodology. Two reviewers independently assessed eligibility. Results: Our search yielded 585 publications; of these, 30 met the full-text review criteria and 16 studies met our criteria for inclusion. We deemed nine articles as having low risk of bias and four as having high risk of bias. Discussion: Commonly used methodologic approaches for clinical trials in underrepresented minority populations included the following: the use of written and visual materials that were no higher than a sixth-grade reading level, the use of patient and lay health navigators, bilingual and multicultural study staff and study materials, race-concordant staff, the option of in-person and virtual visits that accommodated the patient and family's schedule, recruitment from faith communities, and the use of community-engaged research principles. Future palliative care clinical trials should expand on the strategies described in this article, adopt effective strategies currently used in nonpalliative care interventions, and innovate around the principles of community-engaged research.

Perceived discrimination and problematic opioid use among Black individuals with chronic musculoskeletal pain

OBJECTIVE

Chronic musculoskeletal pain (CMP) is prevalent, burdensome, and associated with an increased risk for opioid use disorder. Evidence suggests that perceived racial/ethnic discrimination is associated with problematic substance use among Black individuals, but studies have not focused on problematic opioid use among Black individuals with CMP specifically or explored the contribution of perceived discrimination, pain intensity, and pain-relevant psychological factors to this association.

METHOD

We recruited 401 Black individuals (Mage = 35.98, 51.9% female) with self-reported CMP and prescription opioid use. We tested whether perceived discrimination (a) was associated with self-reported problematic opioid use and (b) explained unique variance in this outcome after accounting for pain intensity, demographic factors, and psychological factors previously implicated in problematic opioid/substance use (distress tolerance and pain avoidance).

RESULTS

Hierarchical linear regression analysis revealed that our model as a whole explained significant variance in problematic opioid use, R² = .30, F(6, 394) = 28.66, p < .001. Perceived discrimination specifically was associated with more problematic opioid use (β = .39, SE = .05, p < .001) and explained unique variance in this outcome even after accounting for pain intensity (β = .06, SE = .04, p = .20), distress tolerance (β = -.10, SE = .05, p = .04), pain avoidance (β = .12, SE = .05, p = .02), age (β = -.10, SE = .05, p < .05), and employment status (β = .13, SE = .11, p < .01).

CONCLUSIONS

Systemic efforts to combat racism along with individualized therapeutic approaches to process and cope with perceived racial discrimination may be particularly important to prevent and reduce problematic opioid use among Black individuals with CMP. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Bridging the gap: Utilizing insights from exposure therapy in the innovation of chronic musculoskeletal pain treatment

For some time, the gold standard treatment for anxiety disorders has been exposure therapy, defined as the repeated approach of anxiety-inducing situations, memories, or physiological sensations. Existing treatments to target fear and avoidance of pain can be augmented by innovations from exposure research in the anxiety disorders, including greater emphasis on safety learning, the utilization of imaginal exposure to catastrophic fears, and exposure to contrasting emotions. Given that treatments to target core, maintaining mechanisms of anxiety, including imaginal exposures, can be administered as self-directed treatments without therapist involvement, they represent important avenues for ensuring the millions of people with chronic musculosketal pain can gain access to psychosocial treatment and reduce the interference of pain in their lives. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of a Mind-Body Program for Chronic Pain in Older versus Younger Adults

Purpose

Improving physical function is key to decreasing the burden of chronic pain across the lifespan. Although mind-body interventions show promise in increasing physical function in chronic pain, very little is known about whether older and younger adults derive similar benefit. Indeed, older adults experience higher rates of chronic pain and greater impacts of pain on physical function compared to younger adults. Therefore, additional work is needed to determine the extent of benefit older versus younger adults receive from a mind-body intervention. Here, we examined age differences in the effects of two mind-body and walking programs on pain and multimodal physical function.

Participants and Methods

Participants were 82 individuals with heterogenous chronic musculoskeletal pain (66% female, 57% aged ≥50 years) who participated in a feasibility randomized controlled trial of two mind-body interventions. They completed self-reported (WHODAS 2.0), performance-based (6-minute walk test), and objective (accelerometer-measured step count) measures of physical function, as well as self-report measures of pain intensity, before and after the intervention.

Results

Results indicated that adults aged ≥50 (vs adults aged <50) demonstrated greater improvements in performance-based physical function (6-minute walk test) and reductions in pain during activity. No age differences in the effects of the intervention on self-reported or objectively measured physical function were observed.

Conclusion

Collectively, these findings suggest that older adults can achieve equivalent or greater benefits from mind-body programs for chronic pain, despite facing unique challenges to chronic pain management (eg, multimorbidity, greater sedentary behavior).

Pain catastrophizing, pain anxiety, and substance use among Black individuals with chronic pain who use opioids

OBJECTIVE

Substance use is the leading cause of preventable deaths in the U.S. Chronic pain is associated with risky substance use. Black individuals experience substantial disparities in pain and substance use outcomes and treatment. Maladaptive psychological reactions to chronic pain, such as pain catastrophizing and pain anxiety, can increase substance use among White individuals. However, no research to date has tested this among Black individuals. This study is the first to test the relationships between pain catastrophizing, pain anxiety, and substance use among Black individuals with chronic pain who use opioid medications.

METHOD

Black adults with chronic pain who use opioids (N = 401) completed online measures of pain catastrophizing (Brief Pain Catastrophizing Scale); pain anxiety (Pain Anxiety Symptom Scale Short Form-20); risky use of alcohol, tobacco, e-cigarettes, cannabis and opioids (Alcohol, Smoking and Substance Involvement Screening Test); and opioid dependence (Severity of Dependence Scale). We conducted zero-inflated and hierarchical regressions to test associations between pain catastrophizing, pain anxiety and substance use (risky use; general use vs. nonuse) above that of demographics, pain intensity and pain interference.

RESULTS

Pain catastrophizing was uniquely associated with risky use of all substances (βs = .03-.09, ps < .001-.02), opioid dependence (β = .13, SE = .05, p = .01), and use (vs. nonuse) of tobacco, alcohol and opioids (βs = .07-.11, ps < .001-.02). Pain anxiety was uniquely associated with tobacco use (vs. nonuse; β = -.02, SE = .01, p = .04) and severity of opioid dependence (β = .21, SE = .01, p < .001).

CONCLUSION

Pain catastrophizing and, to a lesser degree, pain anxiety may be useful intervention targets for this underserved and understudied population. Addressing them may help reduce additional health complications and costs associated with substance use-related risk and dependence. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A Mindfulness-Based Resiliency Program for Caregivers of Patients With Severe Acute Brain Injury Transitioning Out of Critical Care: Protocol for an Open Pilot Trial

BACKGROUND

Caregivers of patients with severe acute brain injuries (SABI) that lead to coma and require intensive care unit (ICU) treatment often experience chronic emotional distress. To address this need, we developed the Coma Family (COMA-F) program, a mindfulness-based resiliency intervention for these caregivers.

OBJECTIVE

We will conduct an open pilot trial of COMA-F (National Institutes of Health Stage IA). Here we describe our study protocol and proposed intervention content.

METHODS

We will enroll 15 caregivers of patients with SABIs during their loved one's hospital course from 3 enrollment centers. A clinical psychologist will deliver the COMA-F intervention (6 sessions) over Zoom (Zoom Video Communications, Inc) or in person. We will iterate COMA-F after each caregiver completes the intervention and an exit interview. English-speaking adults who have emotional distress confirmed by the clinical team and are the primary caregivers of a patient with SABI are eligible. The adult patient must have been admitted to the neuro-ICU for SABI and (1) have had a Glasgow Coma Scale score below 9 while not intubated or an inability to follow meaningful commands while intubated at any point during their hospitalization for >24 hours due to SABI; (2) will be undergoing either tracheostomy or percutaneous endoscopic or surgical gastrostomy tube placement or have already received one or both; and (3) have a prognosis of survival >3 months. We will identify eligible caregivers through screening patients' medical records and through direct referrals from clinicians in the neuro-ICU. During the intervention we will teach caregivers mind-body and resilience skills, including deep breathing, mindfulness, meditation, dialectical thinking, acceptance, cognitive restructuring, effective communication, behavioral activation, and meaning-making. Caregivers will complete self-report assessments (measures of emotional distress and resilience) before and after the intervention. Primary outcomes are feasibility (recruitment, quantitative measures, adherence, and therapist fidelity) and acceptability (treatment satisfaction, credibility, and expectancy). We will conduct brief qualitative exit interviews to gather feedback on refining the program and study procedures. We will examine frequencies and proportions to determine feasibility and acceptability and will analyze qualitative exit interview data using thematic analysis. We will also conduct 2-tailed t tests to explore signals of improvement in emotional distress and treatment targets. We will then conduct an explanatory-sequential mixed methods analysis to integrate quantitative and qualitative data to refine the COMA-F manual and study procedures.

RESULTS

This study has been approved by the institutional review board at 1 of the 3 enrollment centers (2023P000536), with approvals at the other 2 centers pending. We anticipate that the study will be completed by late 2024.

CONCLUSIONS

We will use our findings to refine the COMA-F intervention and prepare for a feasibility randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05761925; https://clinicaltrials.gov/study/NCT05761925.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50860.

Mindfulness-Based App to Reduce Stress in Caregivers of Persons With Alzheimer Disease and Related Dementias: Protocol for a Single-Blind Feasibility Proof-of-Concept Randomized Controlled Trial

BACKGROUND

Informal caregivers (ie, individuals who provide assistance to a known person with health or functional needs, often unpaid) experience high levels of stress. Caregiver stress is associated with negative outcomes for both caregivers and care recipients. Mindfulness-based interventions (MBIs) show promise for improving stress, emotional distress, and sleep disturbance in caregivers of persons with Alzheimer disease and related dementias (ADRD). Commercially available mobile mindfulness apps can deliver MBIs to caregivers of persons with ADRD in a feasible and cost-effective manner.

OBJECTIVE

We are conducting a single-blind feasibility proof-of-concept randomized controlled trial (RCT; National Institutes of Health [NIH] stage 1B) comparing 2 free mobile apps: the active intervention Healthy Minds Program (HMP) with within-app text tailored for addressing stress among caregivers of persons with ADRD, versus Wellness App (WA), a time- and dose-matched educational control also tailored for caregivers of persons with ADRD.

METHODS

We aim to recruit 80 geographically diverse and stressed caregivers of persons with ADRD. Interested caregivers use a link or QR code on a recruitment flyer to complete a web-based eligibility screener. Research assistants conduct enrollment phone calls, during which participants provide informed consent digitally. After participants complete baseline surveys, we randomize them to the mindfulness-based intervention (HMP) or educational control podcast app (WA) and instruct them to listen to prescribed content for 10 minutes per day (70 minutes per week) for 12 weeks. Caregivers are blinded to intervention versus control. The study team checks adherence weekly and contacts participants to promote adherence as needed. Participants complete web-based self-report measures at baseline, posttest, and follow-up; weekly process measures are also completed. Primary outcomes are a priori set feasibility benchmarks. Secondary outcomes are stress, emotional distress, sleep disturbance, caregiver burden, mindfulness, awareness, connection, insight, and purpose. We will calculate 1-sided 95% CI to assess feasibility benchmarks. Effect sizes of change in outcomes will be used to examine the proof of concept.

RESULTS

Recruitment started on February 20, 2023. We have enrolled 27 caregivers (HMP: n=14; WA: n=13) as of June 2023. Funding began in August 2022, and we plan to finish enrollment by December 2023. Data analysis is expected to begin in May 2024 when all follow-ups are complete; publication of findings will follow.

CONCLUSIONS

Through this trial, we aim to establish feasibility benchmarks for HMP and WA, as well as establish a proof of concept that HMP improves stress (primary quantitative outcome), emotional distress, sleep, and mindfulness more than WA. Results will inform a future efficacy trial (NIH stage II). HMP has the potential to be a cost-effective solution to reduce stress in caregivers of persons with ADRD, benefiting caregiver health and quality of care as well as patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05732038; https://clinicaltrials.gov/study/NCT05732038.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50108.

Association of Osteoarthritis and Functional Limitations With Cognitive Impairment Among Older Adults in the United States

Objective: Given overlapping pathophysiology, this study sought to assess the association between osteoarthritis (OA), functional impairment, and cognitive impairment in the aging population. Methods: The National Health and Nutrition Examination Survey was used to identify participants >60 years of age. We analyzed multivariable associations of grouped participants that underwent cognitive function testing using linear and logistic regression, adjusting for sex, age, race, and ethnicity. Results: Of 2776 identified participants representing a population of 50,242,917, 40% did not report OA or functional limitations; 21% had OA but not functional limitations; 15% did not have OA but had functional limitations; 17% had OA and related functional limitations; and 7% had OA and non-arthritic functional limitations. OA was not independently associated with cognitive impairment. Contrarily, functional limitations were associated with cognitive impairment regardless of OA diagnosis. Discussion: Cognitive impairment is not associated with OA, but rather functional limitations, potentially guiding future intervention.

The relationship between mindfulness and enduring somatic threat severity in long-term cardiac arrest survivors

BACKGROUND

Cardiac arrest (CA) survivors experience continuous exposures to potential traumas though chronic cognitive, physical and emotional sequelae and enduring somatic threats (ESTs) (i.e., recurring somatic traumatic reminders of the event). Sources of ESTs can include the daily sensation of an implantable cardioverter defibrillator (ICD), ICD-delivered shocks, pain from rescue compressions, fatigue, weakness, and changes in physical function. Mindfulness, defined as non-judgmental present-moment awareness, is a teachable skill that might help CA survivors cope with ESTs. Here we describe the severity of ESTs in a sample of long-term CA survivors and explore the cross-sectional relationship between mindfulness and severity of ESTs.

METHODS

We analyzed survey data of long-term CA survivors who were members of the Sudden Cardiac Arrest Foundation (collected 10-11/2020). We assessed ESTs using 4 cardiac threat items from the Anxiety Sensitivity Index-revised (items range from 0 "very little" to 4 "very much") which we summed to create a score reflecting total EST burden (range 0-16). We assessed mindfulness using the Cognitive and Affective Mindfulness Scale-Revised. First, we summarized the distribution of EST scores. Second, we used linear regression to describe the relationship between mindfulness and EST severity adjusting for age, gender, time since arrest, COVID-19-related stress, and loss of income due to COVID.

RESULTS

We included 145 CA survivors (mean age: 51 years, 52% male, 93.8% white, mean time since arrest: 6 years, 24.1% scored in the upper quarter of EST severity). Greater mindfulness (β: -30, p = 0.002), older age (β: -0.30, p = 0.01) and longer time since CA (β: -0.23, p = 0.005) were associated with lower EST severity. Male sex was also associated with greater EST severity (β: 0.21, p = 0.009).

CONCLUSION

ESTs are common among CA survivors. Mindfulness may be a protective skill that CA survivors use to cope with ESTs. Future psychosocial interventions for the CA population should consider using mindfulness as a core skill to reduce ESTs.

Integrating Psychosocial Care into Orthopedic Settings: A Qualitative Study of Provider Perspectives

Introduction

Approximately 50% of persons with orthopedic injuries experience psychosocial distress (e.g., depression, anxiety), which can predict chronic pain and disability. Offering psychosocial services in orthopedic settings can promote patient recovery. This study explores health care professionals' perceptions of and recommendations regarding integrated psychosocial care for orthopedic settings.

Methods

We conducted 18 semi-structured focus groups with 79 orthopedic health care professionals (e.g., surgeons, residents, nurses) across three Level I Trauma Centers. This secondary data analysis used the evidence-based Rainbow Model of Integrated Care framework to structure hybrid inductive-deductive qualitative data analysis.

Results

Orthopedic health care professionals identified potential benefits to psychosocial service integration across all dimensions of integration (i.e., clinical, professional, organizational, system, functional, and normative). These benefits included increased patient satisfaction with care, decreased burden on medical providers to manage patient distress, and decreased healthcare utilization costs. They also identified barriers (e.g., fast-paced clinic flow, mental health stigma) and offered recommendations to address barriers across dimensions of integration.

Conclusion

Integrated psychosocial care for orthopedic trauma patients has the potential to improve patient recovery and long-term physical and mental health outcomes. This work identifies strategies to inform the development and implementation of initiatives to integrate psychosocial services within orthopedic settings.

Addressing the Chronic Pain-Early Cognitive Decline Comorbidity Among Older Adults: Protocol for the Active Brains Remote Efficacy Trial

BACKGROUND

Chronic pain and early cognitive decline, which are costly to treat and highly prevalent among older adults, commonly co-occur, exacerbate one another over time, and can accelerate the development and progression of Alzheimer disease and related dementias. We developed the first mind-body activity program (Active Brains [AB]) tailored to the needs of older adults with chronic pain and early cognitive decline. Results from our previous study strongly supported the feasibility of conducting AB remotely and provided evidence for improvements in outcomes.

OBJECTIVE

We are conducting a single-blinded, National Institutes of Health stage-2, randomized clinical trial to establish the efficacy of AB versus a time-matched and dose-matched education control (Health Enhancement Program [HEP]) in improving self-reported and objective outcomes of physical, cognitive, and emotional functions in 260 participants. The methodology described in this paper was informed by the lessons learned from the first year of the trial.

METHODS

Participants are identified and recruited through multidisciplinary clinician-referred individuals (eg, pain psychologists and geriatricians), the Rally Research platform, social media, and community partnerships. Interested participants complete eligibility screening and electronic informed consent. Baseline assessments include self-report, performance-based measures (eg, 6-min walk test) and objective measures (eg, Repeatable Battery for the Assessment of Neuropsychological Status). Participants are mailed a wrist-worn ActiGraph device (ActiGraph LLC) to passively monitor objective function (eg, steps) during the week between the baseline assessment and the beginning of the programs, which they continue to wear throughout the programs. After baseline assessments, participants are randomized to either AB or HEP and complete 8 weekly, remote, group sessions with a Massachusetts General Hospital psychologist. The AB group receives a Fitbit (Fitbit Inc) to help reinforce increased activity. Assessments are repeated after the intervention and at the 6-month follow-up. Coprimary outcomes include multimodal physical function (self-report, performance based, and objective). Secondary outcomes are cognitive function (self-report and objective), emotional function, and pain.

RESULTS

We began recruitment in July 2022 and recruited 37 participants across 4 cohorts. Of them, all (n=37, 100%) have completed the baseline assessment, 26 (70%) have completed the posttest assessment, and 9 (24%) are actively enrolled in the intervention (total dropout: n=2, 5%). In the three cohorts (26/37, 70%) that have completed the AB or HEP, 26 (100%) participants completed all 8 group sessions (including minimal makeups), and watch adherence (1937/2072, 93.48%, average across ActiGraph and Fitbit devices) has been excellent. The fourth cohort is ongoing (9/37, 24%), and we plan to complete enrollment by March 2026.

CONCLUSIONS

We aim to establish the efficacy of the AB program over a time-matched and dose-matched control in a live video-based trial and test the mechanisms through theoretically driven mediators and moderators. Findings will inform the development of a future multisite effectiveness-implementation trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05373745; https://classic.clinicaltrials.gov/ct2/show/NCT05373745.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47319.

A Live Video Dyadic Resiliency Intervention to Prevent Chronic Emotional Distress Early After Dementia Diagnoses: Protocol for a Dyadic Mixed Methods Study

BACKGROUND

By 2030, approximately 75 million adults will be living with Alzheimer disease and related dementias (ADRDs). ADRDs produce cognitive, emotional, and behavioral changes for persons living with dementia that undermine independence and produce considerable stressors for persons living with dementia and their spousal care-partners-together called a "dyad." Clinically elevated emotional distress (ie, depression and anxiety symptoms) is common for both dyad members after ADRD diagnosis, which can become chronic and negatively impact relationship functioning, health, quality of life, and collaborative management of progressive symptoms.

OBJECTIVE

This study is part of a larger study that aims to develop, adapt, and establish the feasibility of Resilient Together for Alzheimer Disease and Related Dementias (RT-ADRD), a novel dyadic skills-based intervention aimed at preventing chronic emotional distress. This study aims to gather comprehensive information to develop the first iteration of RT-ADRD and inform a subsequent open pilot. Here, we describe the proposed study design and procedures.

METHODS

All procedures will be conducted virtually (via phone and Zoom) to minimize participant burden and gather information regarding feasibility and best practices surrounding virtual procedures for older adults. We will recruit dyads (up to n=20) from Mount Sinai Hospital (MSH) clinics within 1 month of ADRD diagnosis. Dyads will be self-referred or referred by their treating neurologists and complete screening to assess emotional distress and capacity to consent to participate in the study. Consenting dyads will then participate in a 60-minute qualitative interview using an interview guide designed to assess common challenges, unmet needs, and support preferences and to gather feedback on the proposed RT-ADRD intervention content and design. Each dyad member will then have the opportunity to participate in an optional individual interview to gather additional feedback. Finally, each dyad member will complete a brief quantitative survey remotely (by phone, tablet, or computer) via a secure platform to assess feasibility of assessment and gather preliminary data to explore associations between proposed mechanisms of change and secondary outcomes. We will conduct preliminary explorations of feasibility markers, including recruitment, screening, live video interviews, quantitative data collection, and mixed methods analyses.

RESULTS

This study has been approved by the MSH Institutional Review Board. We anticipate that the study will be completed by late 2023.

CONCLUSIONS

We will use results from this study to develop the first live video telehealth dyadic resiliency intervention focused on the prevention of chronic emotional distress in couples shortly after ADRD diagnoses. Our study will allow us to gather comprehensive information from dyads on important factors to address in an early prevention-focused intervention and to explore feasibility of study procedures to inform future open pilot and pilot feasibility randomized control trial investigations of RT-ADRD.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/45532.

The Combination of Depression and Obesity was Associated with Increased Incidence of Subsequent Total Knee Arthroplasty

OBJECTIVE

Compare the incidence of total knee arthroplasty (TKA) within the first 5 years after knee OA diagnoses between matched groups of individuals with or without comorbid diagnoses of obesity and/or depression. We hypothesized that the greatest incidence of TKA within 5 years of OA diagnosis would be in the cohort of individuals with combined obesity and depression.

METHODS

The PearlDiver Mariner Ortho157 database was used to identify four cohorts of individuals with knee OA based on diagnosis codes that were matched by age, sex, and Charlson Comorbidity Index: a group without diagnoses associated with depression or obesity (Control), those with obesity but not depression (Obesity), those with depression but not obesity (Depression), and those with diagnoses of both obesity and depression (Depression+Obesity). The incidence of subsequent TKA within the first 5 years after the index OA diagnosis were compared between the four matched cohorts.

RESULTS

Each cohort was comprised of 274,403 unique individuals (180,563 females, 93,840 males; age=55±7 y). The incidence of TKA was greatest for the Depression+Obesity group (11.9%) when compared to the Control group (8.3%, p<0.0001, RR=1.43 [95%CI:1.41,1.45]), the Obesity group (10.2%, p<0.0001, RR=1.13 [95%CI:1.11,1.14], p<0.0001) or Depression (7.8%, p<0.0001, RR=1.53 [95%CI:1.50,1.55], p<0.0001).

CONCLUSION

The incidence of subsequent TKA was greatest for those with the combination of obesity and depression when compared to the Control group and those with individual diagnosis of obesity or depression.

A roadmap for early psychosocial support in palliative care for people impacted by ALS-reducing suffering, building resiliency, and setting the stage for delivering timely transdiagnostic psychosocial care

This commentary describes the current state of psychosocial care for people with amyotrophic lateral sclerosis and their caregivers. We provide recommendations for developing a roadmap for future research based on existing literature and our group's clinical and research experience to inform next steps to expand evidence-based psychosocial care for people with amyotrophic lateral sclerosis and their caregivers, with potential implications for a range of advanced illnesses.

Addressing chronic pain disparities between Black and White people: a narrative review of socio-ecological determinants

A 2019 review article modified the socio-ecological model to contextualize pain disparities among different ethnoracial groups; however, the broad scope of this 2019 review necessitates deeper socio-ecological inspection of pain within each ethnoracial group. In this narrative review, we expanded upon this 2019 article by adopting inclusion criteria that would capture a more nuanced spectrum of socio-ecological findings on chronic pain within the Black community. Our search yielded a large, rich body of literature composed of 174 articles that shed further socio-ecological light on how chronic pain within the Black community is influenced by implicit bias among providers, psychological and physical comorbidities, experiences of societal and institutional racism and biomedical distrust, and the interplay among these factors. Moving forward, research and public-policy development must carefully take into account these socio-ecological factors before scaling up pre-existing solutions with questionable benefit for the chronic pain needs of Black individuals.

Spilling over at the boiling point: A commentary on the need for dyadic approaches to psychosocial care with older adults and their care-partners in postacute rehabilitation

PURPOSE/OBJECTIVE

Older adults typically receive rehabilitation services following an acute medical event within the context of declining health. Post-acute rehabilitation often serves as a "boiling point" for health needs and is met with numerous shared emotional stressors related to recovery, long-term care, and end-of-life considerations among older patients and their care-partners-referred to together as a dyad. Psychosocial intervention that targets patients and care-partners separately misses the opportunity to support dyads who typically navigate health-related emotional challenges together. In the context of chronic and serious illness, dyadic interventions (i.e., patient and informal care-partner, together) can successfully reduce emotional distress as well as improve communication and collaborative illness management. However, this approach has yet to be applied to older post-acute rehabilitation patients and their care-partners.

RESEARCH METHOD/DESIGN

In this commentary, we outline the need for dyadic psychosocial intervention approaches with older adults and their family care-partners in the context of post-acute rehabilitation.

RESULTS

First, we provide evidence for the potential benefits of a dyadic approach to psychosocial care. Next, we review theoretical models as well as clinically relevant confounding factors that can inform dyadic psychosocial case conceptualization and intervention. Finally, we offer a real-world clinical case example that demonstrates the opportunity for dyadic intervention to address common psychosocial challenges seen by psychologists in post-acute rehabilitation settings.

CONCLUSIONS/IMPLICATIONS

Our goal is to encourage rehabilitation psychologists to view dyadic intervention as a first-line approach to psychosocial care with the growing population of older adults and their family care-partners in post-acute rehabilitation settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

"Alone in the dark": A qualitative study of treatment experiences among young adults with a recent concussion and anxiety

PURPOSE

Young adults with anxiety are vulnerable to developing persistent symptoms following concussions. In order to develop psychosocial interventions to prevent persistent post-concussion symptoms, we need to understand patients' 1) experiences with treatments offered by health care providers; 2) experiences with attempted concussion management strategies; and 3) needs after their injury.

METHODS

We conducted in-depth interviews with 17 young adults with recent (≤ 10 weeks) concussions who have at least mild anxiety (Generalized Anxiety Disorder Assessment-7 ≥ 5). We used a hybrid deductive-inductive approach to thematic analysis.

RESULTS

Findings provide insight into recommended treatments (e.g., active/avoidant strategies, accommodations, referrals), attempted strategies (e.g., lifestyle changes, pacing, relationships, acceptance-based coping skills), and patient needs (e.g., education, accommodations, referrals for cognitive and emotional skills). Participants frequently expressed that treatment recommendations were confusing and difficult to implement. They initiated non-prescribed strategies that helped promote recovery and expressed a desire for more interdisciplinary treatment and education on concussions.

CONCLUSION

Patients' perceptions of health care provider recommendations after concussions did not fully meet patients' perceived needs. Young adults with concussions and anxiety would benefit from more education, guidance, and psychosocial and rehabilitation services. Addressing these gaps may help align treatments with patients' needs and therefore help optimize their recovery.

The impact of a virtual mind-body program on resilience factors among international English-speaking adults with neurofibromatoses: secondary analysis of a randomized clinical trial

PURPOSE

To test the effects of the Relaxation Response Resiliency Program - Neurofibromatosis (3RP-NF), a mind-body resilience program for people with NF, on resilience factors from baseline to post-treatment and 6- and 12-month follow-up.

METHODS

This is a secondary analysis of a fully powered randomized clinical trial (RCT) of 3RP-NF and health education control (HEP-NF). We recruited adults with NF1, NF2, or schwannomatosis who reported stress or difficulty coping with NF symptoms. Both conditions received 8 weekly 90-minute group sessions; 3RP-NF focused on building resilience skills. We measured resilience factors via the Measure of Current Status-A (adaptive coping), Cognitive and Affective Mindfulness Scale-Revised (mindfulness), Gratitude Questionnaire-6 (gratitude), Life Orientation Test Optimism Scale (optimism), and Medical Outcomes Study Social Support Survey (perceived social support) at baseline, post-intervention, and 6- and 12-month follow-up. We used linear mixed models with completely unstructured covariance across up to four repeated measurements (baseline, post-treatment, and 6- and 12-month follow-up) to investigate treatment effects on resilience factors.

RESULTS

We enrolled 228 individuals (Mage=42.7, SD = 14.6; 74.5% female; 87.7% White; 72.8% NF1, 14.0% NF2, 13.2% schwannomatosis). Within groups, both 3RP-NF and HEP-NF showed statistically significant improvements in all outcomes across timepoints. 3RP-NF showed significantly greater improvement in adaptive coping compared to HEP-NF from baseline to post-intervention and baseline to 6 months (Mdifference= 0.29; 95% CI 0.13-0.46; p < 0.001; Mdifference= 0.25; 95% CI 0.07-0.33; p = 0.005); there were no other between-group differences amongst the remaining resilience factors.

CONCLUSION

3RP-NF showed promise in sustainably improving coping abilities amongst people with NF.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov Identifier: NCT03406208. Registration submitted December 6, 2017, first patient enrolled October 2017.

Health disparities in orthopedic trauma: a qualitative study examining providers' perspectives on barriers to care and recovery outcomes

Social workers involved in interdisciplinary orthopedic trauma care can benefit from the knowledge of providers' perspectives on healthcare disparities in this field. Using qualitative data from focus groups conducted on 79 orthopedic care providers at three Level 1 trauma centers, we assessed their perspectives on orthopedic trauma healthcare disparities and discussed potential solutions. Focus groups originally aimed to detect barriers and facilitators of the implementation of a trial of a live video mind-body intervention to aid in recovery in orthopedic trauma care settings (Toolkit for Optimal Recovery-TOR). We used the Socio-Ecological Model to analyze an emerging code of "health disparities" during data analysis to determine at which levels of care these disparities occurred. We identified factors related to health disparities in orthopedic trauma care and outcomes at the Individual (Education- comprehension, health-literacy; Language Barriers; Psychological Health- emotional distress, alcohol/drug use, learned helplessness; Physical Health- obesity, smoking; and Access to Technology), Relationship (Social Support Network), Community (Transportation and Employment Security), and Societal level (Access- safe/clean housing, insurance, mental health resources; Culture). We discuss the implications of the findings and provide recommendations to address these issues, with a specific focus on their relevance to the field of social work in health care.

Resilient together-ALS: leveraging the NDD transdiagnostic framework to develop an early dyadic intervention for people with amyotrophic lateral sclerosis and their informal care-partners

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive weakness and eventual death, usually within 3-5 years. An ALS diagnosis is associated with substantial emotional distress for both the affected person and their family care-partners which impairs the ability to engage in important conversations about long term care planning, negatively impacts ALS symptoms for the patient, and quality of life for both patient and care-partner. Here we 1) discuss published works identified by the authors about psychosocial interventions for the ALS population, 2) identify a lack of early, dyadic interventions to support psychosocial needs of people with ALS and care-partners; 3) describe the Neurodegenerative Diseases (NDD) framework for early dyadic intervention development and 4) propose an adaptation of an evidence-based early dyadic psychosocial intervention, Recovering Together, for the unique needs of people with ALS and their care-partners (Resilient Together-ALS; RT-ALS) using the NDD framework. Future work will use stakeholder feedback to optimize the intervention for subsequent efficacy testing.

Effect of Mind-Body Skills Training on Quality of Life for Geographically Diverse Adults With Neurofibromatosis: A Fully Remote Randomized Clinical Trial

Importance

Neurofibromatoses (NF; NF1, NF2, and schwannomatosis) are hereditary tumor predisposition syndromes with a risk for poor quality of life (QOL) and no evidence-based treatments.

Objective

To compare a mind-body skills training program, the Relaxation Response Resiliency Program for NF (3RP-NF), with a health education program (Health Enhancement Program for NF; HEP-NF) for improvement of quality of life among adults with NF.

Design, Setting, and Participants

This single-blind, remote randomized clinical trial randomly assigned 228 English-speaking adults with NF from around the world on a 1:1 basis, stratified by NF type, between October 1, 2017, and January 31, 2021, with the last follow-up February 28, 2022.

Interventions

Eight 90-minute group virtual sessions of 3RP-NF or HEP-NF.

Main Outcomes and Measures

Outcomes were collected at baseline, after treatment, and at 6-month and 1-year follow-up. The primary outcomes were physical health and psychological domain scores of the World Health Organization Quality of Life Brief Version (WHOQOL-BREF). Secondary outcomes were the social relationships and environment domain scores of the WHOQOL-BREF. Scores are reported as transformed domain scores (range, 0-100, with higher scores indicating higher QOL). Analysis was performed on an intention-to-treat basis.

Results

Of 371 participants who underwent screening, 228 were randomized (mean [SD] age, 42.7 [14.5] years; 170 women [75%]), and 217 attended 6 or more of 8 sessions and provided posttest data. Participants in both programs improved from baseline to after treatment in primary outcomes of physical health QOL score (3RP-NF, 5.1; 95% CI, 3.2-7.0; P < .001; HEP-NF, 6.4; 95% CI, 4.6-8.3; P < .001) and psychological QOL score (3RP-NF, 8.5; 95% CI, 6.4-10.7; P < .001; HEP-NF, 9.2; 95% CI, 7.1-11.2; P < .001). Participants in the 3RP-NF group showed sustained improvements after treatment to 12 months; posttreatment improvements for the HEP-NF group diminished (between-group difference for physical health QOL score, 4.9; 95% CI, 2.1-7.7; P = .001; effect size [ES] = 0.3; and psychological QOL score, 3.7; 95% CI, 0.2-7.6; P = .06; ES = 0.2). Results were similar for secondary outcomes of social relationships and environmental QOL. There were significant between-group differences from baseline to 12 months in favor of the 3RP-NF for physical health QOL score (3.6; 95% CI, 0.5-6.6; P = .02; ES = 0.2), social relationships QOL score (6.9; 95% CI, 1.2-12.7; P = .02; ES = 0.3), and environmental QOL score (3.5; 95% CI, 0.4-6.5; P = .02; ES = 0.2).

Conclusions and Relevance

In this randomized clinical trial of 3RP-NF vs HEP-NF, benefits from 3RP-NF and HEP-NF were comparable after treatment, but at 12 months from baseline, 3RP-NF was superior to HEP-NF on all primary and secondary outcomes. Results support the implementation of 3RP-NF in routine care.

Trial Registration

ClinicalTrials.gov Identifier: NCT03406208.

How Do Orthopaedic Providers Conceptualize Good Patient Outcomes and Their Barriers and Facilitators After Acute Injury? A Qualitative Study

BACKGROUND

Good clinical outcomes in orthopaedics are largely dictated by the biomedical model, despite mounting evidence of the role of psychosocial factors. Understanding orthopaedic providers' conceptualizations of good clinical outcomes and what facilitates and hinders them may highlight critical barriers and opportunities for training providers on biopsychosocial models of care and integrating them into practice.

QUESTIONS/PURPOSES

(1) How do orthopaedic trauma healthcare providers define good clinical outcomes for their patients after an acute orthopaedic injury? (2) What do providers perceive as barriers to good outcomes? (3) What do providers perceive as facilitators of good outcomes? For each question, we explored providers' responses in a biopsychosocial framework.

METHODS

In this cross-sectional, qualitative study, we recruited 94 orthopaedic providers via an electronic screening survey from three Level I trauma centers in geographically diverse regions of the United States (rural southeastern, urban southwestern, and urban northeastern). This study was part of the first phase of a multisite trial testing the implementation of a behavioral intervention to prevent chronic pain after acute orthopaedic injury. Of the 94 participants who were recruited, 88 completed the screening questionnaire. Of the 88 who completed it, nine could not participate because of scheduling conflicts. Thus, the final sample included 79 participants: 48 surgeons (20 attendings, 28 residents; 6% [three of 48] were women, 94% [45 of 48] were between 25 and 55 years old, 73% [35 of 48] were White, and 2% [one of 48] were Hispanic) and 31 other orthopaedic professionals (10 nurse practitioners, registered nurses, and physician assistants; 13 medical assistants; five physical therapists and social workers; and three research fellows; 68% [21 of 31] were women, 97% [30 of 31] were between 25 and 55 years old, 71% [22 of 31] were White, and 39% [12 of 31] were Hispanic). Using a semistructured interview, our team of psychology researchers conducted focus groups, organized by provider type at each site, followed by individual exit interviews (5- to 10-minute debriefing conversations and opportunities to voice additional opinions one-on-one with a focus group facilitator). In each focus group, providers were asked to share their perceptions of what constitutes a "good outcome for your patients," what factors facilitate these outcomes, and what factors are barriers to achieving those outcomes. Focus groups were approximately 60 minutes long. A research assistant recorded field notes during the focus groups to summarize insights gained and disseminate findings to the broader research team. Using this procedure, we determined that thematic saturation was reached for all topics and no additional focus groups were necessary. Three independent coders identified the codes of good outcomes, outcome barriers, and outcome facilitators and applied this coding framework to all transcripts. Three separate data interpreters collaboratively extracted themes related to biomedical, psychological, and social factors and corresponding inductive subthemes.

RESULTS

Although orthopaedic providers' definitions of good outcomes naturally included biomedical factors (bone healing, functional independence, and pain alleviation), they were also marked by nuanced psychosocial factors, including the need for patients to recover from psychological trauma associated with injury and feel heard and understood-not just as outcome facilitators, but also as key outcomes themselves. Regarding perceived barriers to good outcomes, providers interwove psychological and biomedical factors (for example, "if they're a smoker, if they have depression, anxiety…") and discussed how psychological dysfunction (for example, maladaptive avoidance or fear of reinjury) can limit key behaviors during recovery (such as adherence to physical therapy regimens). Unprimed, providers also cited resiliency-related terms from psychological research, including (low) "self-efficacy," "catastrophic thinking," and (lack of) psychological "hardiness" as barriers. Regarding perceived facilitators of good outcomes, various social and socioeconomic factors emerged, including a biosocial connection between recovery, social support, and "privilege" (such as occupation or education). These perspectives emerged across sites and provider types.

CONCLUSION

Although the biomedical model prevails in clinical practice, providers across all sites, in various roles, defined good outcomes and their barriers and facilitators in terms of interconnected biopsychosocial factors without direct priming to do so. Thus, similar Level I trauma centers may be more ready to adopt biopsychosocial care approaches than initially expected.

CLINICAL RELEVANCE

Providers' perspectives in this study aligned with a growing body of research on the role of biomedical and psychosocial factors in surgical outcomes and risk of transition to chronic pain. To translate these affirming attitudes into practice, other Level I trauma centers could encourage leaders who adopt biopsychosocial approaches to share their perspectives and train other providers in biopsychosocial conceptualization and treatment.

Protective positive psychology factors and emotional distress after cardiac arrest

BACKGROUND

There is a critical need to identify factors that can prevent emotional distress post-cardiac arrest (CA). CA survivors have previously described benefitting from utilizing positive psychology constructs (mindfulness, existential well-being, resilient coping, social support) to cope with distress. Here, we explored associations between positive psychology factors and emotional distress post-CA.

METHODS

We recruited CA survivors treated from 4/2021-9/2022 at a single academic medical center. We assessed positive psychology factors (mindfulness [Cognitive and Affective Mindfulness Scale-Revised], existential well-being [Meaning in Life Questionnaire Presence of Meaning subscale], resilient coping [Brief Resilient Coping Scale], perceived social support [ENRICHD Social Support Inventory]) and emotional distress (posttraumatic stress [Posttraumatic Stress Checklist-5], anxiety and depression symptoms [PROMIS Emotional Distress - Anxiety and Depression Short Forms 4a]) just before discharge from the index hospitalization. We selected covariates for inclusion in our multivariable models based on an association with any emotional distress factor (p < 0.10). For our final, multivariable regression models, we individually tested the independent association of each positive psychology factor and emotional distress factor.

RESULTS

We included 110 survivors (mean age 59 years, 64% male, 88% non-Hispanic White, 48% low income); 36.4% of survivors scored above the cut-off for at least one measure of emotional distress. In separate adjusted models, each positive psychology factor was independently associated with emotional distress (β: -0.20 to -0.42, all p < 0.05).

CONCLUSIONS

Higher levels of mindfulness, existential well-being, resilient coping, and perceived social support were each associated with less emotional distress. Future intervention development studies should consider these factors as potential treatment targets.

Occurrence and Severity of Suicidal Ideation in Adults With Neurofibromatosis Participating in a Mind-Body RCT

BACKGROUND

Emotional distress can lead to suicidal ideation and potentially suicide completion, yet there is very little literature on suicidal ideation in individuals with a diagnosis of neurofibromatosis (NF; NF1, NF2, and schwannomatosis).

OBJECTIVE

To examine the baseline occurrence, severity, and clinical correlates of suicidal ideation in adults with NF.

METHOD

Individuals with NF (N = 220) completed assessments measuring depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), perceived stress (Perceived Stress Scale-10), pain (Graded Chronic Pain Scale and PROMIS Pain Interference Short Form 8a), and general quality of life (World Health Organization Quality of Life-Brief version) before beginning a two-arm, single-blind randomized control trial of a live-video mind-body program for stress management and resiliency.

RESULTS

Nineteen percent (n = 42) of the individuals experienced suicidal ideation (ie, >0; ideation present several days or greater). More individuals with NF2 experienced suicidal ideation compared with those with NF1 or schwannomatosis. All of the clinical variables except pain intensity were significantly correlated ( P < 0.01) with greater suicidal ideation. Suicidal ideation in individuals with NF was comparable to or higher than that in other medical populations (eg, cancer, dermatological, neurologic). Depression and poor psychological quality of life significantly increased the risk for suicidal ideation.

CONCLUSION

Suicidal ideation was relatively prevalent in individuals with NF seeking participation in a mind-body randomized controlled trial. NF clinicians should be prepared to discuss these concerns and provide resources when suicidal ideation is present.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (Identifier NCT03406208).