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                 American Association on Health and Disability



Military lower extremity amputee rehabilitation.
Hermes LM. Physical Medicine and Rehabilitation Clinic and Electrodiagnostic
Laboratory, Irwin Army Community Hospital, Fort Riley, Kansas, USA.
Phys Med Rehabil Clin N Am. 2002 Feb;13(1):45-66.

The role of the military has changed over the past eight decades. Although the threat of
global warfare still exists, the military of today faces new challenges as a peacekeeper in
countries under turmoil. Despite these changes, the fear of bodily injury, such as limb
loss and even the possibility of death, are real concerns for our active duty personnel.
The military physician must be aware of the appropriate surgical, rehabilitative, and
psychosocial needs of the lower extremity traumatic amputee. The physical medicine
and rehabilitation specialist is a physician particularly suited to provide direction for and
to oversee the overall care of the amputee's condition. An amputee center providing a
multidisciplinary team approach has worked well for the military during war and
peacetimes. The physical medicine and rehabilitation inpatient service at WRAMC
continues the tradition and philosophy of the military amputee centers dating back to
WWI. By growing with the fast-paced technologic advances in prosthetic devices, yet
keeping true to the fundamentals of prosthetic prescription and design, physical
medicine and rehabilitation in the military has remained at the forefront of amputee
rehabilitation. Patient satisfaction with the rehabilitation process and his or her new
artificial limb remain priorities whether the goal is to return to active duty or to resume an
active lifestyle in the civilian world.

The military upper extremity amputee.
Petri RP Jr, Aguila E. Department of Surgery, William Beaumont Army Medical Center,
El Paso, Texas, USA. Phys Med Rehabil Clin N Am. 2002

Throughout the course of military history, soldiers have continued to sustain amputation
injuries during war times and during peacetime and training missions. What has changed
over time is the etiology of, indication for, and management of the amputations.
Technology has advanced significantly, often with some military connection. More work
still needs to be done, especially in the areas of greater prosthetic limb function and
usage as well as phantom pain and sensation management. Collaborative efforts among
physiatrists, surgeons, prosthetists, and therapists can only benefit the patient.

The prevalence of knee pain and symptomatic knee osteoarthritis among veteran
traumatic amputees and nonamputees.
Norvell DC, Czerniecki JM, Reiber GE, Maynard C, Pecoraro JA, Weiss NS.
Health Services Research and Development, Seattle, WA, USA. Arch Phys Med Rehabil. 2005 Mar;86(3):487-93. Comment
in: Arch Phys Med Rehabil. 2005 Jun;86(6):1273.

OBJECTIVE: To determine whether amputees have an increased risk of knee pain or
symptomatic osteoarthritis (OA) compared with nonamputees.

DESIGN: Retrospective cohort study.

SETTING: Veterans Administration Patient Treatment and Outpatient Care files.

PARTICIPANTS: All male unilateral (transtibial or transfemoral) traumatic amputee
patients and a random sample of male nonamputees. Patients were excluded if they
were younger than 40 years, had sustained a significant injury to their knee(s), or had a
rheumatic disease.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: The prevalence of knee pain and symptomatic knee OA.

RESULTS: The age and average weight-adjusted prevalence ratio of knee pain among
transtibial amputees, compared with nonamputees, was 1.3 (95% confidence interval
[CI], 0.7-2.1) for the knee of the intact limb and 0.2 (95% CI, .05-0.7) for the knee of the
amputated limb. The standardized prevalence ratio of knee pain in the intact limb and
symptomatic OA among transfemoral amputees, compared with nonamputees, was 3.3
(95% CI, 1.5-6.3) and 1.3 (95% CI, 0.2-4.8), respectively.

CONCLUSIONS: Stresses on the contralateral knee of amputees may contribute to
secondary disability. Possible explanations include gait abnormalities, increased
physiologic loads on the knee of the intact limb, and the hopping and stumbling behavior
common in many younger amputees.


Perceived barriers to health care access in a treated population.
Bauer MS, Williford WO, McBride L, McBride K, Shea NM. Veterans Affairs Medical
Center, Providence, Rhode Island, USA. Int J Psychiatry Med.

OBJECTIVE: Health care access may be a significant contributor to health outcome.
However, few data exist on perception of barriers by patients in treatment, and attending
a clinic visit does not mean that no barriers exist. Understanding barriers for treated
populations is particularly important in optimizing care for high vulnerability populations,
such as those with mental illness and the elderly.

METHOD: A structured interview, demographic questionnaire, and SF-12 were
administered to 324 veterans presenting for primary care or mental health appointments

at a Veterans Affairs medical center. Principle components analysis was performed and
relationships to vulnerability characteristics were identified.

RESULTS: Most interview items showed modest mean levels but high variance.
Responses were stable over three to six weeks. As hypothesized, perceived total
barriers were greater in participants from several vulnerable populations: those receiving
treatment for mental health problems, those with disabilities, and those with worse
physical and mental function. Minority participants did not perceive greater barriers. An
"inverted-U" relationship with age was found. Principal components analysis assigned 18
items across six clinically meaningful subscales. Participants with mental health
treatment perceived greater barriers in three subscales including provider
communication. Curvilinear relationships were again seen between subscales and age.

CONCLUSIONS: Even individuals "in care" perceive barriers. Members of vulnerable
populations, particularly those receiving mental health treatment, perceive greater
barriers. Data support a multi-dimensional conceptualization of perceived barriers, and
different subgroups experience different patterns of barriers.


Exercise rehabilitation improves functional outcomes and peripheral circulation in
patients with intermittent claudication: a randomized controlled trial.
Gardner AW, Katzel LI, Sorkin JD, Bradham DD, Hochberg MC, Flinn WR, Goldberg AP.
Claude D. Pepper Older Americans Independence Center, Department of Medicine,
Division of Gerontology, University of Maryland, Baltimore, MD, USA. J Am Geriatr Soc.
2001 Jun;49(6):755-62.

OBJECTIVE: To determine the effects of a 6-month exercise program on ambulatory
function, free-living daily physical activity, peripheral circulation, and health-related
quality of life (QOL) in disabled older patients with intermittent claudication.

DESIGN: Prospective, randomized controlled trial.

SETTING: University Medical (Center and Veterans Affairs Medical Center, Baltimore,

PARTICIPANTS: Thirty-one of 61 patients with Fontaine stage II peripheral arterial
occlusive disease (PAOD) were randomized to exercise rehabilitation and 30 to usual-
care control. Three patients from the exercise group and six patients from the control
group dropped out, leaving 28 and 24 patients, respectively, completing the study in
each group.

INTERVENTION: Six months of exercise rehabilitation.

MEASUREMENTS: Treadmill distance walked to onset of claudication and to maximal
claudication, ambulatory function, peripheral circulation, perceived QOL, and daily
physical activity.

RESULTS: Compliance with the exercise program was 73% of the possible sessions.
Exercise rehabilitation increased treadmill distance walked to onset of claudication by

134% (P < .001) and to maximal claudication by 77% (P < .001), walking economy by
12% (P = .003), 6-minute walk distance by 12% (P < .001), and maximal calf blood flow
by 30% (P < .001). Changes in distance walked to maximal pain correlated with changes
in walking economy (r = -.50, P = .013) and changes in maximal calf blood flow (r = .38,
P = .047). Exercise rehabilitation increased accelerometer-derived daily physical activity
by 38% (P < .001); this change correlated with the change in distance walked to maximal
pain (r = .45, P = .020). These improvements were significantly better than the changes
in the control group (P < .05).
CONCLUSION: Improvements in claudication following exercise rehabilitation in older
PAOD patients are dependent on improvements in peripheral circulation and walking
economy. Improvement in treadmill claudication distances in these patients translated
into increased accelerometer-derived physical activity in the community, which enabled
the patients to become more functionally independent.


Hearing health and care: The need for improved hearing loss prevention and
hearing conservation practices.
Fausti SA, Wilmington DJ, Helt PV, Helt WJ, Konrad-Martin D.
VA RR&D NCRAR, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97239. J Rehabil Res Dev. 2005 Jul-Aug;42(4 Suppl 2):45-62.

Hearing loss affects 31 million Americans, particularly veterans who were exposed to
harmful levels of noise during military functions. Many veterans also receive treatment
with ototoxic medications, which may exacerbate preexisting hearing loss. Thus, hearing
loss is the most common and tinnitus the third most common service-connected
disability among veterans. Poor implementation of hearing protection programs and a
lack of audiometric testing during medical treatment leave veterans vulnerable to
unrecognized and untreated hearing loss until speech communication is impaired.
Individualized audiometric testing techniques, including assessment of high frequencies,
can be used in clinical and occupational settings to detect early hearing loss.
Antioxidants also may alleviate cochlear damage caused by noise and ototoxicity.
Ultimately, hearing loss prevention requires education on reducing occupational and
recreational noise exposure and counseling on the risks and options available to
patients. Technological advances will improve monitoring, allow better noise engineering
controls, and lead to more effective hearing protection.


Combat duty in Iraq and Afghanistan, mental health problems, and barriers to
Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Department of
Psychiatry and Behavioral Sciences, Walter Reed Army Institute of Research, U.S. Army
Medical Research and Materiel Command, Silver Spring, Md 20910, USA. N Engl J Med. 2004 Jul 1;351(1):13-22. Comment
in: N Engl J Med. 2004 Jul 1;351(1):75-7. N Engl J Med. 2004 Oct 21;351(17):1798-800;
author reply 1798-800.

BACKGROUND: The current combat operations in Iraq and Afghanistan have involved
U.S. military personnel in major ground combat and hazardous security duty. Studies are
needed to systematically assess the mental health of members of the armed services
who have participated in these operations and to inform policy with regard to the optimal
delivery of mental health care to returning veterans.

METHODS: We studied members of four U.S. combat infantry units (three Army units
and one Marine Corps unit) using an anonymous survey that was administered to the
subjects either before their deployment to Iraq (n=2530) or three to four months after
their return from combat duty in Iraq or Afghanistan (n=3671). The outcomes included
major depression, generalized anxiety, and post-traumatic stress disorder (PTSD), which
were evaluated on the basis of standardized, self-administered screening instruments.

RESULTS: Exposure to combat was significantly greater among those who were
deployed to Iraq than among those deployed to Afghanistan. The percentage of study
subjects whose responses met the screening criteria for major depression, generalized
anxiety, or PTSD was significantly higher after duty in Iraq (15.6 to 17.1 percent) than
after duty in Afghanistan (11.2 percent) or before deployment to Iraq (9.3 percent); the
largest difference was in the rate of PTSD. Of those whose responses were positive for
a mental disorder, only 23 to 40 percent sought mental health care. Those whose
responses were positive for a mental disorder were twice as likely as those whose
responses were negative to report concern about possible stigmatization and other
barriers to seeking mental health care.

CONCLUSIONS: This study provides an initial look at the mental health of members of
the Army and the Marine Corps who were involved in combat operations in Iraq and
Afghanistan. Our findings indicate that among the study groups there was a significant
risk of mental health problems and that the subjects reported important barriers to
receiving mental health services, particularly the perception of stigma among those most
in need of such care.

Use of psychiatric and medical health care by veterans with severe mental illness.
Bosworth HB, Calhoun PS, Stechuchak KM, Butterfield MI. Durham Veterans Affairs
Medical Center, North Carolina 27705, USA. Psychiatr
Serv. 2004 Jun;55(6):708-10.

Risk behaviors and health care use among 396 initially hospitalized veterans with severe
mental illnesses were examined. Health care use was abstracted from Veterans Affairs
databases (March 1998 to June 2000) for one year after hospital discharge. Lifetime
intravenous drug use was related to increased use of outpatient services, and current
alcohol use was related to decreased health care use. Patients with posttraumatic stress
disorder had greater use of medical outpatient services than patients with schizophrenia-
spectrum disorders, although they had longer hospital stays. These results highlight that
veterans with severe mental illness receive more treatment in medical than psychiatric
health clinics.


Prevalence and correlates of depression among veterans with multiple sclerosis.
Williams RM, Turner AP, Hatzakis M Jr, Bowen JD, Rodriquez AA, Haselkorn JK.
Department of Veterans Administration Puget Sound Health Care System, Seattle
Division, Rehabilitation Care Services, S-117, 1660 S. Columbian Way, Seattle, WA
98108, USA. Neurology. 2005 Jan 11;64(1):75-80.

OBJECTIVES: To establish the prevalence of major depressive episode (MDE) in a
large sample of veterans with multiple sclerosis (MS); to identify demographic
characteristics, aspects of disease presentation, and perceptions of disability associated
with greater concurrent risk for MDE; and to examine the relationship between MDE,
service utilization, and activity participation.

METHODS: Veterans with MS (n = 1,032) were identified via computer database and
surveyed by mail; 451 (43.7%) responded.

RESULTS: Twenty-two percent of the sample met criteria for current MDE. Low income,
unemployment, presence of falls, younger age, absence of a marital partner, and high
levels of perceived disability due to bowel functioning were independently associated
with MDE. Disease subtype, disease duration, use of disease modifying therapies, and
perceived disability due to mobility or bladder problems were unrelated to MDE. Current
MDE was in turn associated with increased primary care visits and increased impact of
disease upon activity participation. Similar correlates were associated with minor
depressive episode.

CONCLUSIONS: Unlike the general population, rates of depression in this
predominantly male sample were similar to those found in predominantly female
samples of persons with multiple sclerosis. Specific aspects of disability were
differentially associated with depression, and depression was independently associated
with increased service utilization and increased participation limitations.

Treatment patterns of multiple sclerosis patients: a comparison of veterans and
non-veterans using the NARCOMS registry.
Lo AC, Hadjimichael O, Vollmer TL. Department of Neurology, Yale School of Medicine
and VA Connecticut Healthcare System, West Haven, CT 06516, USA. Mult Scler. 2005 Feb;11(1):33-40.

Multiple sclerosis (MS) is a chronic illness of the central nervous system, with a highly
variable clinical course. Available therapies are only partially effective and as a
consequence treatment patterns between patients can be varied. Longitudinal
databases consisting of large cohorts where successive and sequential data is collected
may reveal disease and treatment characteristics not apparent when data is gathered
during clinical trials that consist usually of relatively homogeneous patients followed for
short durations. We analysed data from the North American Research Committee on
Multiple Sclerosis registry, a self-reported database, to assess MS patient characteristics
and treatment patterns, with a focus on veterans. We show that the Veteran Healthcare
Administration (VHA) system of medical centres care for a greater number of patients
with higher average disability but not necessarily patients who report primary
progressive or actively worsening disease. We also show that the VHA medical centres
appear to better provide multidisciplinary care, particularly in the areas of social work,
physical therapy and urology. In general, treatment patterns for symptomatic therapies

follow similar patterns across veterans and non-veterans groups. Treatment patterns for
immunomodulatory agents suggest that VHA veterans use IMA less frequently than
either non-VHA veterans or non-veterans.


Military and VA general dentistry training: a national resource.
Atchison KA, Bachand W, Buchanan CR, Lefever KH, Lin S, Engelhardt R.
UCLA School of Dentistry, CHS, Los Angeles, CA 90095, USA. J
Dent Educ. 2002 Jun;66(6):739-46.

In 1999, HRSA contracted with the UCLA School of Dentistry to evaluate the
postgraduate general dentistry (PDG) training programs. The purpose of this article is to
compare the program characteristics of the PGD training programs sponsored by the
Armed Services (military) and VA. Surveys mailed to sixty-six VA and forty-two military
program directors in fall 2000 sought information regarding the infrastructure of the
program, the program emphasis, resident preparation prior to entering the program, and
a description of patients served and types of services provided. Of the eighty-one
returned surveys (75 percent response rate), thirty were received from military program
directors and fifty-one were received from VA program directors. AEGDs reported
treating a higher proportion of children patients and GPRs more medically intensive,
disadvantaged and HIV/AIDS patients. Over half of the directors reported increases in
curriculum emphasis in implantology. The program directors reported a high level of
inadequate preparation among incoming dental residents. Having a higher ratio of
residents to total number of faculty predicted inadequate preparation (p=.022) although
the model was weak. Although HRSA doesn't financially support federally sponsored
programs, their goal of improved dental training to care for medically compromised
individuals is facilitated through these programs, thus making military and VA general
dentistry programs a national resource.


Ethnicity, control appraisal, coping, and adjustment to chronic pain among black
and white Americans.
Tan G, Jensen MP, Thornby J, Anderson KO. Houston VA Medical Center, Houston,
Texas 77030, USA. Pain Med. 2005 Jan-Feb;6(1):18-28.

OBJECTIVE: To identify similarities and differences among non-Hispanic black and
white patients in pain appraisal, beliefs about pain, and ways of coping with pain. We
also examined the association between these factors (i.e., appraisals, beliefs, coping)
and patient perception or subjective experience of their functioning in each ethnic group.

DESIGN: Cross-sectional survey of patients with chronic pain at pretreatment

SETTING: Integrated pain management program at a Veterans Affairs Medical Center in

PATIENTS: A total of 128 non-Hispanic black Americans and 354 non-Hispanic white
Americans completed self-report measures of pain appraisal, coping, and adjustment
that included the Multidimensional Pain Inventory, Survey of Pain Attitudes, Coping
Strategies Questionnaire, and Chronic Pain Coping Inventory.

RESULTS: Although the analyses indicated many similarities between the two groups
concerning pain-related beliefs and coping, the black patients reported lower perceived
control over pain, more external pain-coping strategies, and a stronger belief that others
should be solicitous when they experience pain. The black patients also reported
significantly higher levels of depression and disability, even after controlling for pain
severity. Regression analyses revealed that the coping and appraisal factors predicting
physical and psychological functioning were the same for both white and black patients,
with ethnicity accounting for a nonsignificant amount of the total variance.

CONCLUSIONS: The current findings suggest similarities as well as differences
between non-Hispanic black and white patients in the ways they view and cope with
pain. However, the association between psychological factors (attitudes and beliefs,
coping responses) and adjustment to chronic pain was comparable for both ethnic
groups. If replicated, the findings suggest that specific tailoring of cognitive behavioral
therapies to different racial/ethnic groups may not be needed to maximize treatment


Burden of medical illness in women with depression and posttraumatic stress
Frayne SM, Seaver MR, Loveland S, Christiansen CL, Spiro A 3rd, Parker VA, Skinner
KM. Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System,
Menlo Park, Calif, USA. Arch Intern Med. 2004 Jun

BACKGROUND: Depression and posttraumatic stress disorder (PTSD) are important
women's health issues. Depression is known to be associated with poor physical health;
however, associations between physical health and PTSD, a common comorbidity of
depression, have received less attention.

OBJECTIVES: To examine number of medical symptoms and physical health status in
women with PTSD across age strata and benchmark them against those of women with
depression alone or with neither depression nor PTSD.

METHODS: A random sample of Veterans Health Administration enrollees received a
mailed survey in 1999-2000 (response rate, 63%). The 30 865 women respondents were
categorized according to whether a health care provider had ever told them that they
had PTSD, depression (without PTSD), or neither. Outcomes were self-reported medical
conditions and physical health status measured with the Veterans SF-36 instrument, a
version of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)
modified for use in veteran populations.

RESULTS: Across age strata, women with PTSD (n = 4348) had more medical
conditions and worse physical health status (physical functioning, role limitations due to

physical problems, bodily pain, and energy/vitality scales from the Veterans SF-36) than
women with depression alone (n = 7580) or neither (n = 18 937). In age-adjusted
analyses, the Physical Component Summary score was on average 3.4 points lower in
women with depression alone and 6.3 points lower in women with PTSD than in women
with neither (P<.001).

CONCLUSIONS: Posttraumatic stress disorder is associated with a greater burden of
medical illness than is seen with depression alone. The presence of PTSD may account
for an important component of the excess medical morbidity and functional status
limitations seen in women with depression.

Gender Differences in service connection for PTSD.
Murdoch M, Hodges J, Hunt C, Cowper D, Kressin N, O'Brien N. Center for Chronic
Disease Outcomes Research and Section of General Internal Medicine, Minneapolis VA
Medical Center, and Department of Internal Medicine, University of Minnesota School of
Medicine, Minneapolis Minnesota 55417, USA. Med Care. 2003
Aug;41(8):950-61. Comment in: Med Care. 2003 Dec;41(12):1417; author reply 1417-8.

BACKGROUND: Mentally ill female veterans obtain a smaller proportion of their care
from Department of Veterans Affairs (VA) facilities than mentally ill male veterans do,
possibly because women are less likely than men to be service connected for psychiatric
disabilities. "Service connected" veterans have documented, compensative conditions
related to or aggravated by military service, and they receive priority for enrollment into
the VA healthcare system.

OBJECTIVES: To see if there are gender discrepancies in rates of service connection
for posttraumatic stress disorder (PTSD) and, if so, to see if these discrepancies could
be attributed to appropriate subject characteristics (eg, differences in symptom severity
or impairment).

RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were
conducted on 11% of the sample. SUBJECTS: Randomly selected veterans seeking VA
disability benefits for PTSD. Women were oversampled to achieve a gender ratio of 1:1.

RESULTS: A total of 3337 veterans returned usable surveys (effective response rate,
68%). Men's unadjusted rate of service connection for PTSD was 71%; women's, 52%
(P < 0.0001). Adjustment for veterans' PTSD symptom severity or functional impairment
did not appreciably reduce this discrepancy, but adjustment for dissimilar rates of
combat exposure did. Estimated rates of service connection were 53% for men and 56%
for women after adjusting for combat exposure. This combat preference could not be
explained by more severe PTSD symptoms or greater functional impairment.

CONCLUSIONS: Instead of a gender bias in awards for PTSD service connection, we
found evidence of a combat advantage that disproportionately favored men. The
appropriateness of this apparent advantage is unclear and needs further investigation.

Improving the rates of quitting smoking for veterans with posttraumatic stress
McFall M, Saxon AJ, Thompson CE, Yoshimoto D, Malte C, Straits-Troster K, Kanter E,

Zhou XH, Dougherty CM, Steele B. PTSD Programs (S-116 MHC), VA Puget Sound
Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA. Am J Psychiatry. 2005 Jul;162(7):1311-9.

OBJECTIVE: Smoking is highly prevalent and refractory among people with
posttraumatic stress disorder (PTSD). This study aimed to improve the rate of quitting
smoking for veterans with PTSD by integrating treatment for nicotine dependence into
mental health care.

METHOD: Smokers undergoing treatment for PTSD (N=66) were randomly assigned to
1) tobacco use treatment delivered by mental health providers and integrated with
psychiatric care (integrated care) versus 2) cessation treatment delivered separately
from PTSD care by smoking-cessation specialists (usual standard of care). Seven-day
point prevalence abstinence was the primary outcome, measured at 2, 4, 6, and 9
months after random assignment. Data were analyzed by using a generalized estimating
equations approach following the intent-to-treat principle.

RESULTS: Subjects assigned to integrated care were five times more likely than
subjects undergoing the usual standard of care to abstain from smoking across follow-up
assessment intervals (odds ratio=5.23). Subjects in the integrated care condition were
significantly more likely than subjects in usual standard of care to receive transdermal
nicotine and nicotine gum. They also received a greater number of smoking-cessation
counseling sessions. Stopping smoking was not associated with worsening symptoms of
PTSD or depression.

CONCLUSIONS: Smoking-cessation interventions can be safely incorporated into
routine mental health care for PTSD and are more effective than treatment delivered
separately by a specialized smoking-cessation clinic. Integrating cessation treatment into
psychiatric care may have the potential for improving smoking quit rates in other
populations of chronically mentally ill smokers.

Mitigating effect of Department of Veterans Affairs disability benefits for post-
traumatic stress disorder on low income.
Murdoch M, van Ryn M, Hodges J, Cowper D. Minneapolis VAMC/Center for Chronic
Disease Outcomes Research and Department of Medicine, University of Minnesota
School of Medicine, One Veterans Drive (111-0), Minneapolis, MN 55417, USA. Mil
Med. 2005 Feb;170(2):137-40.

OBJECTIVE: The goal was to assess the impact of Veterans Affairs (VA) disability
benefits for post-traumatic stress disorder (PTSD) on veterans' odds of poverty. Women
and African American veterans were of special interest, because they are less likely than
other groups to receive PTSD disability benefits.

METHODS: A cross-sectional survey of 4,918 veterans who applied for VA disability
benefits for PTSD between 1994 and 1998 was performed. Responses were linked to
administrative data.

RESULTS: Overall, 42% reported low income (defined as household income less than or
equal to 20,000 dollars per year). Men's and women's odds of reporting poverty were
similar, but receipt of PTSD disability benefits mediated African American veterans' odds

of poverty. Veterans' odds of impoverishment were reduced considerably if they received
VA PTSD disability benefits and identified themselves as disabled.

CONCLUSIONS: VA disability benefits for PTSD reduced odds of impoverishment for
psychiatrically ill veterans. This effect appeared to be especially important for African
American veterans and for veterans self-identifying as disabled.

PTSD symptoms, demographic characteristics, and functional status among
veterans treated in VA primary care clinics.
Magruder KM, Frueh BC, Knapp RG, Johnson MR, Vaughan JA 3rd, Carson TC, Powell
DA, Hebert R. Veterans Affairs Medical Center, Charleston, South Carolina 29401-
5799, USA. J Trauma Stress. 2004 Aug;17(4):293-301.

We hypothesized that PTSD symptomatology would have an inverse relationship with
functional status and would vary as a function of sociodemographic variables. Primary
care patients (N = 513) at two VA Medical Centers were randomly selected and recruited
to participate. After adjustment for other demographic variables, PTSD symptom levels
were significantly related to age (younger patients had more severe symptoms),
employment status (disabled persons had higher symptom levels), war zone experience,
and clinic location. PTSD symptomatology was inversely related to mental and physical
functioning, even after control for potential confounding. These findings have
implications for screening and service delivery in VA primary care clinics, and support
the more general finding in the literature that PTSD is associated with impaired

PTSD and Treatment Adherence: the role of health beliefs.
Spoont M, Sayer N, Nelson DB. Center for Chronic Disease Outcome Research, VA
Medical Center, Minneapolis, MN 55417, USA. J Nerv Ment Dis. 2005 Aug;193(8):515-

Health beliefs have been shown to influence a myriad of medical treatment decisions.
More recently, the impact of health beliefs on treatment decisions for mental illness has
become a focus of study. This study examines the health beliefs and treatment behavior
of veterans with posttraumatic stress disorder (PTSD). Using standard survey
methodology, we assessed beliefs about the cause of PTSD, expected duration and
controllability of symptoms, and life consequences of having PTSD. Treatment
participation and medication compliance were assessed, as were common treatment
correlates, such as patient-provider relationships, dosing frequency, side effect severity,
number of prescribed medications, and use of drugs or alcohol to control PTSD
symptoms. Explanatory models of PTSD, perceived controllability, and use of
benzodiazepines were found to predict psychiatric medication use. Negative life
consequences of PTSD were associated with participation in psychotherapy.
Assessment of health beliefs may help providers to understand their patients' treatment
behavior and to facilitate treatment engagement.

Predicting high-risk behaviors in veterans with posttraumatic stress disorder.
Hartl TL, Rosen C, Drescher K, Lee TT, Gusman F. Health Services Research and

Development, VA Palo Alto Health Care System, Palo Alto, CA, USA. J Nerv Ment Dis.
2005 Jul;193(7):464-72.

The present study sought to identify posttraumatic stress disorder (PTSD) patients at
high risk for negative behavioral outcomes (violence, suicide attempts, and substance
use). The Mississippi Scale for Combat-Related PTSD, the Beck Depression Inventory,
and demographic and behavioral data from 409 male combat veterans who completed a
VA residential rehabilitation program for PTSD were analyzed using signal detection
methods (receiver operating characteristics). A validation sample (N = 221) was then
used to test interactions identified in the signal detection analyses. The best predictors of
behaviors at follow-up were those same behaviors shortly before intake, followed by
depressive and PTSD symptoms. However, for each of the models other than that for
hard drug use, cutoffs determined at the symptom level did not lend themselves to
replication. Recent high-risk behaviors, rather than patients' history, appear to be more
predictive of high-risk behaviors postdischarge.

Predictors of psychosocial adaptation among people with spinal cord injury or
Martz E, Livneh H, Priebe M, Wuermser LA, Ottomanelli L. Educational, School, and
Counseling Psychology Department, Dept. 4B Hill Hall, University of Missouri, Columbia,
MO 65211-2130, USA. Arch Phys Med Rehabil. 2005

OBJECTIVE: To examine the influence of disability-related medical and psychologic
variables on psychosocial adaptation to spinal cord injury or disorder (SCI/D).

DESIGN: A structural equation modeling design linking 3 sets of predictive variables to
an outcome measure of adaptation.

SETTING: Two outpatient SCI clinics (1 veteran, 1 civilian) in Texas. PARTICIPANTS:
Veterans (n=181) and civilians (n=132) with SCI/D.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: The adaptation outcome was measured by 2 subscales
(acknowledgment, adjustment) of the Reactions to Impairment and Disability Inventory
(RIDI) and by the Quality of Life Scale. The predictive variables were measured by a
demographic questionnaire, 3 subscales (intrusion, re-experiencing, hyperarousal) of the
Purdue Posttraumatic Stress Disorder-Revised scale, the McMordie-Templer Death
Anxiety Scale, and 3 subscales (anxiety, depression, denial) of the RIDI.

RESULTS: Goodness-of-fit indices suggested that a revised model of adaptation was a
moderately good fit to the data. The revised model of adaptation indicated that there
were medium total effects (direct plus indirect) on psychosocial adaptation by 2 latent
variables (disability severity and impact, negative affectivity) and small total effects on
psychosocial adaptation by disengagement coping. The latent factor of disengagement
coping had the strongest direct effect on adaptation (although not statistically
significant). Disability severity and impact had medium indirect effects and negative
affectivity had small indirect effects on psychosocial adaptation. All of the
aforementioned effects had a negative coefficient.

CONCLUSIONS: Negative emotional responses (eg, depression, anxiety) to SCI/D,
disengagement-type coping (eg, disability denial, avoidance), and the severity and
impact of disability were related to lower levels of adaptation to SCI/D.

Psychiatric interventions with returning soldiers at Walter Reed.
Wain H, Bradley J, Nam T, Waldrep D, Cozza S. Department of Psychiatry, Walter
Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307-5001,
USA. Psychiatr Q. 2005 Winter;76(4):351-60.

War is a malefic force and results in many psychiatric and medical casualties.
Psychiatry's involvement with soldiers experiencing psychological stress resulting from
combat experience has been reported for many years (Zajtchuk, 1995). It has been
demonstrated that a myriad of diagnosis to include depression, anxiety, somatoform,
adjustment disorders and psychotic behaviors also emerge (Wain et al., 1996, 2005a).
Nearly all survivors exposed to traumatic events briefly exhibit one or more stress
related symptoms (Morgan et al., 2003). In many instances these symptoms dissipate
within a reasonable amount of time. However, symptoms persisting for a prolonged
period following a traumatic event increase the probability of developing stress-related
psychiatric disorders.

Regional variation and other correlates of Department of Veterans Affairs
Disability Awards for patients with posttraumatic stress disorder.
Murdoch M, Hodges J, Cowper D, Sayer N. Center for Chronic Disease Outcomes
Research, Minneapolis VA Medical Center, Minnesota 55417, USA. Med Care. 2005 Feb;43(2):112-21.

BACKGROUND: Minnesota, Minneapolis, Minnesota. Posttraumatic stress disorder
(PTSD) is a chronic disabling condition affecting more than 600,000 United States
veterans and is the most common psychiatric condition for which veterans seek
Veterans Affairs disability benefits. Receipt of such benefits enhances veterans' access
to Veteran Affairs health care and reduces their chance of poverty.

OBJECTIVES: We sought to determine whether previously identified regional variations
in PTSD disability awards are explained by appropriate subject characteristics (eg,
differences in PTSD symptomatology or dysfunction) and to estimate the impact of
veterans' PTSD symptom severity or level of dysfunction on their odds of obtaining
PTSD disability benefits.

RESEARCH DESIGN: We used a mailed survey linked to administrative data.

SUBJECTS: Subjects included 4918 representative, eligible men and women who filed
PTSD disability claims between 1994 and 1998.

RESULTS: A total of 3337 veterans returned useable surveys (68%). Before adjustment,
PTSD disability claims approval rates ranged from 43% to 75% across regions. After
adjustment, rates ranged from 33% to 72% (P <0.0001). Severer PTSD symptoms were
associated with greater odds of having PTSD disability benefits (P <0.0001).
Unexpectedly, poorer functional status was associated with lower odds of having

benefits (P <0.0001). On average, clinical differences between veterans who did and did
not have PTSD disability benefits were small but suggested slightly greater dysfunction
among those without benefits.

CONCLUSIONS: An almost twofold regional difference in claims approval rates was not
explained by veterans' PTSD symptom severity, level of dysfunction, or other subject-
level characteristics. Veterans who did not obtain PTSD disability benefits were at least
as disabled as those who did receive benefits.

Subthreshold PTSD in primary care: prevalence, psychiatric disorders, healthcare
use, and functional status.
Grubaugh AL, Magruder KM, Waldrop AE, Elhai JD, Knapp RG, Frueh BC.
VA Medical Center, Charleston, South Carolina 29425, USA. J Nerv Ment Dis. 2005

The purpose of this study is to determine the prevalence of subthreshold posttraumatic
stress disorder (PTSD) and its association with specific traumas, other psychiatric
diagnoses, healthcare use, and functional status among 669 veterans in four VA Medical
Centers. A cross-sectional, epidemiological design incorporating self-report measures,
structured interviews, and chart reviews was used to obtain relevant information for
analyses. Comparisons across three trauma-exposed groups (PTSD, subthreshold
PTSD, no PTSD) revealed that veterans in the subthreshold PTSD group did not use
mental health services more often than those in the no PTSD group despite the
presence of additional mental health diagnoses and worse functional status. These data
indicate that clinicians may be overlooking a subset of individuals suffering from
subsyndromal PTSD, suggesting the need to detect and serve these individuals better
within healthcare settings.

Veterans seeking disability benefits for post-traumatic stress disorder: who
applies and the self-reported meaning of disability compensation.
Sayer NA, Spoont M, Nelson D. Center for Chronic Diseases Outcomes Research,
Veterans Affairs Medical Center 116A6, One Veterans Drive, Minneapolis, MN 55417,
USA. Soc Sci Med. 2004 Jun;58(11):2133-43.

Assumptions about the characteristics and motivations of individuals pursuing disability
status are well known. However, policy, programming and interventions need to be
based on information about the actual sociodemographic characteristics of disabled
individuals, as well as their goals in seeking disability status. In this study, we focus on
veterans seeking disability compensation for post-traumatic stress disorder (PTSD) from
the United States Department of Veterans Affairs. We present information on their life
circumstances and their self-reported reasons for valuing the obtainment of veterans'
disability status on the basis of PTSD. There was considerable variability in the
background of veterans seeking disability status on the basis of PTSD. Of concern, only
about half of these individuals were receiving any mental health treatment at the time of
application. Most claimants reported seeking disability compensation for symbolic
reasons, especially for acknowledgement, validation and relief from self-blame. Reasons
having to do with improved finances were less frequently endorsed, although the
importance of obtaining improved solvency through disability status decreased as
income increased. The sense of investment in obtaining a sense of self-acceptance and
acceptance from others through disability status varied by sociodemographic variables.

Overall, findings suggest that individuals seeking disability benefits may have unmet
mental health care needs, and that policy makers, investigators and providers should
consider material benefit as one of many possible reasons for engaging in a disability
compensation system.

War-related mental health problems of today's veterans: new clinical awareness.
Reeves RR, Parker JD, Konkle-Parker DJ. G.V. (Sonny) Montgomery VA Medical
Center, Jackson, Mississippi 39216, USA. J Psychosoc Nurs
Ment Health Serv. 2005 Jul;43(7):18-28.

1. Veterans of the military conflicts in Iraq and Afghanistan may have been exposed to
significant psychological stressors, resulting in mental and emotional disorders. 2.
Posttraumatic stress disorder (PTSD) is characterized by symptoms in three domains:
reexperiencing the trauma, avoiding stimuli associated with the trauma, and symptoms
of increased autonomic arousal. 3. Treatment of PTSD often requires both psychological
and pharmacological interventions. 4. In addition to PTSD, other mental disorders may
be precipitated or worsened by exposure to combat, including depression, anxiety,
psychosis, and substance abuse.


Maintaining support in people with paralysis: what works?
Devereux PG, Bullock CC, Bargmann-Losche J, Kyriakou M. School of Public Health,
University of Nevada, Reno, USA. Qual Health Res. 2005 Dec;15(10):1360-76.

Social support is a protective factor for well-being in the risk-and-resilience framework,
yet people with paralysis report lower levels of support compared to people without
paralysis. Rather than examine deficits, in this study, the authors conducted in-depth
interviews with individuals who report high levels of social support to examine what
sustains this protective factor. Because relationship equity affects social support, the
authors also examined this. They selected participants who reported high levels of
support from a survey sample of 299 U.S. adults experiencing some form of paralysis.
Seventeen participants completed the in-depth interview. The importance of reciprocity,
maintaining autonomy, and a positive outlook for sustaining support were themes
identified in the content analysis. In their responses, people with high support
emphasized that they do all they can to affect their environment positively, so that
ideally, the only assistance that they cannot provide themselves is successfully obtained
from others.


Upper limb pain in a national sample of veterans with paraplegia.
Gironda RJ, Clark ME, Neugaard B, Nelson A. Chronic Pain Rehabilitation Program,
James A. Haley Veterans' Hospital, Tampa, Florida 33612, USA. J Spinal Cord Med. 2004;27(2):120-7.

BACKGROUND AND OBJECTIVES: The purpose of this survey study was to examine
the prevalence and intensity of pain and associated patient characteristics in a national

sample of veterans with paraplegia. Of particular interest were upper limb (UL) pain
conditions, which pose unique challenges to individuals who use a wheelchair for
mobility. Because the risk for UL pain conditions appears to increase over time, the
associations among age, duration of wheelchair use, and UL pain were evaluated.

METHODS: A group of 1,675 individuals between the ages of 18 and 65 with a lesion
between T2 and L2 and a mailing address on file were selected randomly from the
Veteran's Affairs Spinal Cord Dysfunction Registry and mailed a survey packet. Of the
deliverable packets, approximately 46% were completed and returned.

RESULTS: Approximately 81% of the respondents reported at least a minimal level of
ongoing unspecified pain and 69% experienced current UL pain. Shoulder pain intensity
was most severe during the performance of wheelchair-related mobility and
transportation activities, suggesting that UL pain may have a significant impact on
functional independence. Duration of wheelchair use modestly predicted shoulder pain
prevalence and intensity, but age and the interaction between age and duration of
wheelchair use did not.

CONCLUSION: The data of the present study suggest that the development,
persistence, and exacerbation of UL pain conditions in persons with paraplegia are
multidimensional processes. A comprehensive theoretic model is needed to integrate the
existing empiric literature in this area.


Body mass index in spinal cord injury -- a retrospective study.
Gupta N, White KT, Sandford PR. Department of Physical Medicine and Rehabilitation,
Clement J Zablocki VA Medical Center, Medical College of Wisconsin, Milwaukee, WI
53295, USA. Spinal Cord. 2006 Feb;44(2):92-4.

STUDY DESIGN: Retrospective chart review.

OBJECTIVE: To identify the prevalence of overweight and severely overweight (obese)
in veterans with spinal cord injury.

SETTING: Veterans Administration Hospital in Wisconsin.

METHODS: A retrospective chart review of all the patients registered in the current
database with the Spinal Cord Injury Unit in the Veterans Administration Hospital was
undertaken Data collected for each patient included age, sex, height, date of
assessment of the height, weight, date of assessment of the weight, duration of spinal
cord injury and the type of spinal cord injury -- paraplegia versus quadriplegia. The body
mass index (BMI) was subsequently calculated for each patient and the prevalence of
overweight and obesity were determined.

RESULTS: There were a total of 408 patients registered in the database with the Spinal
Injury Unit. The median age was 56 years, and the mean age 55.8 years. Of all patients
with spinal cord injury, 52.2% patients had paraplegia and 47.7% had quadriplegia. The
mean duration of injury was 19 years. Of the total number of patients, 46.0% were ASIA
A, 11.0% were ASIA B, 12.7% were ASIA C and 29.1% were ASIA D. In all, 27.9%

patients had a normal BMI and 3.6% patients were undernourished (BMI less than 18.5
kg/m(2)). The prevalence of overweight was 65.8% and 29.9% patients were obese.

CONCLUSION: Overweight and obesity are problems of a significant magnitude in
veterans with spinal cord injury.

Death anxiety as a predictor of posttraumatic stress levels among individuals with
spinal cord injuries.
Martz E. Dept. of Educational and Counseling Psychology, University of Missouri,
Columbia, Missouri, USA. Death Stud. 2004 Jan;28(1):1-17.

Because the onset of a spinal cord injury may involve a brush with death and because
serious injury and disability can act as a reminder of death, death anxiety was examined
as a predictor of posttraumatic stress levels among individuals with disabilities. This
cross-sectional study used multiple regression and multivariate multiple regression to
examine whether death denial and death awareness predicted posttraumatic stress
disorder (PTSD) among veterans and civilians with spinal cord injuries (N = 313). The
results indicated that death anxiety (after controlling for demographic and disability-
related variables) predicted a significant amount of the total levels of posttraumatic
stress reactions among individuals with spinal cord injuries. Further, death awareness,
pain level, and spiritual/religious coping significantly predicted the posttraumatic stress
clusters of reexperiencing, avoidance, and hyperarousal. Death denial significantly
predicted only hyperarousal. Because death anxiety predicts various aspects of PTSD
reactions, one possible therapeutic implication is that addressing death-related topics
may help to reduce PTSD reactions. Further research is needed to better ascertain the
possible causality among these variables.

Disease prevalence and use of preventive services: comparison of female
veterans in general and those with spinal cord injuries and disorders.
Lavela SL, Weaver FM, Smith B, Chen K. Spinal Cord Injury Quality Enhancement
Research Initiative (SCI QUERI), Midwest Center for Health Services and Policy
Research (MCHSPR), Hines, IL 60141, USA. J Womens Health
(Larchmt). 2006 Apr;15(3):301-11.

BACKGROUND: Disease prevalence and use of preventive services may differ between
women veterans in general and those with spinal cord injuries and disorders (SCI&D).
Prevention is particularly important in SCI&D, and disparities may exist in receipt of this
care, particularly when special equipment and body adjustments are needed, among
women with SCI&D.

METHODS: To compare disease prevalence and preventive service use among female
veterans in general and those with SCI&D, we conducted a cross-sectional survey
among female veterans in general (n = 478) and those with SCI&D (n = 115). Behavioral
Risk Factor Surveillance System (BRFSS) survey questions were administered to
veterans with SCI&D and compared with 2003 CDC BRFSS data.

RESULTS: Female veterans with SCI&D were similar in age and race but were better
educated and less likely to be employed than female veterans in general. Coronary heart
disease (CHD) prevalence was higher in those with SCI&D (17% vs. 8%, p < 0.0001).
Health status was lower in SCI&D (27%) than in general female veterans (41%), p =

0.002. Fewer women with SCI&D, than female veterans in general reported having
received recommended dental care (56% vs. 69%, p = 0.004), colon screening in prior 5
years (59% vs. 72%, p = 0.023) or prior 10 years (67% vs. 92%, p< 0.0001),
mammogram (84% vs. 91%, p = 0.019), and Pap smear (88% vs. 98%, p < 0.0001).
There were no differences in receipt of respiratory vaccinations or cholesterol screening.

CONCLUSIONS: Receipt of services that require the use of equipment, body
adjustments, and potential discomfort due to disability was lower in women with SCI&D.
Veterans Affairs (VA) is doing well in most areas, but there are gaps in receipt of some
preventive services. Efforts to increase preventive care in women with SCI&D should
address equipment and access barriers and patient and provider education.

Preliminary assessment of a prototype advanced mobility device in the work
environment of veterans with spinal cord injury.
Cooper RA, Boninger ML, Cooper R, Fitzgerald SG, Kellerher A. Human Engineering
Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA 15206, USA. NeuroRehabilitation. 2004;19(2):161-70.

The INDEPENDENCE 3000 IBOT Transporter (IBOT) is an electronically stabilizing
device for people with disabilities. The purpose of this study was to collect qualitative
data on the potential for the IBOT to improve employment satisfaction of veterans who
use wheelchairs to work. This study was based upon observations by trained clinicians,
and responses to a survey completed by four men with traumatic spinal cord injury, who
worked in an office environment. The mean age of the subjects was 52 +/- 8.8 years.
The subjects used the devices to hold eye-level discussions with colleagues, climb
stairs, ascend steep ramps, and negotiate curbs. When subjects were asked to rate the
ease of getting around in the IBOT compared to their personal wheelchairs, they
responded with a mean of 6.7 +/- 1.8 on a 10-point visual analog scale. The response to
rating the overall function of the IBOT within their working environment yielded a rating
of 6.0 +/- 2.8. Half of the users felt that the IBOT would help them at work and all thought
it should be made available to veterans who use wheelchairs. A larger study should be
conducted to determine if the IBOT affects work performance and the ability to return to

Pressure ulcers in veterans with spinal cord injury: a retrospective study.
Garber SL, Rintala DH. Houston Veterans Affairs Medical Center, Baylor College of
Medicine, Houston, TX 77030, USA. J Rehabil Res Dev. 2003

Pressure ulcers are a major complication of spinal cord injury (SCI) and have a
significant effect on general health and quality of life. The objectives of this retrospective
chart review were to determine prevalence, duration, and severity of pressure ulcers in
veterans with SCI and to identify predictors of (1) outcome in terms of healing without
surgery, not healing, or referral for surgery; (2) number of visits veterans made to the
SCI outpatient clinic or received from home care services for pressure ulcer treatment;
and (3) number of hospital admissions and days hospitalized for pressure ulcer
treatment. From a sampling frame of 553 veterans on the Houston Veterans Affairs
Medical Center SCI roster, 215 (39%) were reported to have visited the clinic or received
home care for pressure ulcers (ICD-9 code 707.0 = decubitus, any site) during the 3

years studied (1997, 1998, and 1999). From this sample, 102 veterans met the inclusion
criteria for further analyses, 56% of whom had paraplegia. The duration of ulcers varied
greatly from 1 week to the entire 3-year time-frame. Overall, Stage IV pressure ulcers
were the most prevalent as the worst ulcer documented. Number and severity of ulcers
predicted outcome and healthcare utilization. This study illustrates the magnitude of the
pressure ulcer problem among veterans with SCI living in the community. Reducing the
prevalence of pressure ulcers among veterans with SCI will have a significant impact on
the Department of Veterans Affairs' financial and social resources. Innovative
approaches are needed to reduce pressure ulcer risk in veterans with SCI.

Subjective stress in male veterans with spinal cord injury.
Rintala DH, Robinson-Whelen S, Matamoros R. Michael E. DeBakey Department of
Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX 77030,
USA. J Rehabil Res Dev. 2005 May-Jun;42(3):291-304.

We undertook a telephone survey to examine perceived stress among 165 veterans with
spinal cord injury (SCI) who received care from a Department of Veterans Affairs
Medical Center. Measures included Perceived Stress Scale, Hassles Scale, Center for
Epidemiologic Studies Depression Scale, Short-Form State-Trait Anxiety Inventory,
Satisfaction with Life Scale, and Short-Form Interpersonal Support Evaluation List. The
mean perceived stress score for our sample of veterans with SCI (17.3) was higher than
the means for men from the general population (12.1) and nonveteran men with SCI
(13.9). Physical abilities, health, and financial issues were frequently reported hassles.
Stress was related positively to depressive symptomatology and anxiety and negatively
to life satisfaction. The association of hassles with measures of psychological well-being
was partially mediated by perceived stress. The association of perceived stress with
depression and anxiety varied as a function of social support, suggesting that those with
low social support are the most vulnerable to the negative impact of stress on their
psychological well-being. Stress management programs designed specifically to meet
the needs of veterans with SCI are needed.


Upper extremity reconstruction in the tetraplegic population, a national
epidemiologic study.
Curtin CM, Gater DR, Chung KC. Robert Wood Johnson Clinical Scholar Program,
University of Michigan-Ann Arbor, Medical Science Building 1, 11560 W. Medical Center
Drive, Ann Arbor, MI 48109, USA. J Hand Surg [Am]. 2005 Jan;30(1):94-9.

PURPOSE: More than 100,000 Americans live with the disability of tetraplegia. For
these people their level of independence often is related to the function of the upper
extremity. Reconstructive procedures can improve the use of the upper limb and multiple
case series have shown benefit from these procedures for appropriate candidates.
Discussions with patients and surgeons, however, suggest that these procedures rarely
are performed. This study attempted to assess whether upper extremity reconstruction
for the tetraplegic population is being used properly.

METHODS: Data from 2 inpatient national databases were used (the National Inpatient
Sample and Veterans Affairs patient treatment files) for 1988, 1989, 1999, and 2000.

Patients were selected by International Classification of Diseases (ICD-9) diagnosis
codes for tetraplegia and procedure codes that could represent upper extremity
reconstruction. The recommended rate of these surgeries was based on the annual
incidence of tetraplegia (5,000) and expert opinion that suggests at least 50% of these
people would benefit from upper extremity surgery.

RESULTS: Our health care data analysis showed that fewer than 355 of these surgeries
were performed in the United States in any year queried. The calculated recommended
rate was 2,500 procedures a year, meaning that only 14% of appropriate candidates
were receiving upper extremity reconstruction. We also found changes in the expected
primary payor, with Medicaid paying for far fewer procedures in 2000 compared with
1988 claims. Finally over the course of time it appears that far fewer of these procedures
are being performed.

CONCLUSIONS: Functional upper extremity reconstruction for the tetraplegic population
is profoundly underused in the United States. Various factors could be causing this
disparity of care and we recommend further research into the potential barriers to health
care for this vulnerable population.


Coronary artery disease and risk factors in people with posttraumatic vision loss.
Defrin R, Holtzman S, Katz M, Heruti R, Ohry A, Drory Y. Department of Physical
Therapy, Sackler School of Medicine, Tel-Aviv University, Israel.
Arch Phys Med Rehabil. 2005 May;86(5):968-73.

OBJECTIVE: To examine the prevalence of coronary artery disease (CAD) and its risk
factors in people with posttraumatic vision loss (PTVL).

DESIGN: Cross-sectional, controlled study.

SETTING: The general community.

PARTICIPANTS: Study groups included 82 subjects with PTVL, 49 siblings, 58 blind
subjects with retinitis pigmentosa (RP), and the general population in Israel.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Sociodemographic and biomedical data collected by
using a structured questionnaire and medical records.

RESULTS: The prevalence of CAD among subjects with PTVL (24%) was 2 to 3 times
higher than the control groups ( P <.001). However, the prevalence of the CAD risk
factors in these subjects was similar to or lower than those in the control groups. For
example, significantly fewer subjects with PTVL were physically inactive (16%) than
patients with RP (55%, P <.01). The only variable that was significantly associated with
CAD prevalence was the cause of blindness-that is, trauma versus disease; the odds of
having CAD after traumatic vision loss was 3.75 times higher than after RP.

CONCLUSIONS: People with PTVL exhibit elevated rates of risk for CAD similar to
those of other groups with physical disability. The traumatic injury that caused vision loss
might be an important factor underlying that risk.

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