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BACKGROUND AND PURPOSE: DTI is a tool for microstructural spinal cord injury evaluation. This study evaluated the reproducibility of a semiautomated segmentation algorithm of spinal cord DTI. MATERIALS AND METHODS: Forty-two consecutive patients undergoing acute trauma cervical spine MR imaging underwent 2 axial DTI scans in addition to their clinical scan. The datasets were put through a semiautomated probabilistic segmentation algorithm that selected white matter, gray matter, and 24 individual white matter tracts. Regional and white matter tract volume, fractional anisotropy, and mean diffusivity values were calculated. Two readers performed the nonautomated steps to evaluate interreader reproducibility. The coefficient of variation and intraclass correlation coefficient were used to assess test-retest and interreader reproducibility. RESULTS: Of 42 patients, 30 had useable data. Test-retest reproducibility of fractional anisotropy was high for white matter as a whole (coefficient of variation, 3.8%; intraclass correlation coefficient, 0.93). Test-retest coefficient-of-variation ranged from 8.0%-18.2% and intraclass correlation coefficients from 0.47-0.80 across individual white matter tracts. Mean diffusivity metrics also had high test-retest reproducibility (white matter: coefficient-of-variation, 5.6%; intraclass correlation coefficient, 0.86) with coefficients of variation from 11.6%-18.3% and intraclass correlation coefficients from 0.57-0.74 across individual tracts, with better agreement for larger tracts. The coefficients of variation of fractional anisotropy and mean diffusivity both had significant negative relationships with white matter volume (26%-27% decrease for each doubling of white matter volume, P < .01). CONCLUSIONS: DTI spinal cord segmentation is reproducible in the setting of acute spine trauma, specifically for larger white matter tracts and total white or gray matter.

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STUDY DESIGN: Cross-sectional. OBJECTIVE: The objective of the study is to examine whether alcohol use disorders should be conceptualized categorically as abuse and dependence as in the 'Diagnostic and Statistical Manual of Mental Disorders' 4th edition or on a single continuum with mild to severe category ratings as in the 'Diagnostic and Statistical Manual of Mental Disorders' 5th edition in people with spinal cord injury (SCI). SETTING: United States of America. METHODS: Data from 379 individuals who sustained SCI either traumatically or non-traumatically after the age of 18 and were at least 1 year post injury. Rasch analyses used the alcohol abuse and dependence modules of the Structured Clinical Interview for DSM-IV-TR Axis I Disorders Non-patient Edition (SCID-I/NP). RESULTS: Fifty-seven percent (n=166) of the entire sample endorsed criteria for alcohol abuse, and 25% (n=65) endorsed criteria for alcohol dependence. Fit values were generally acceptable except for one item (for example, alcohol abuse criterion 2), suggesting that the items fit the expectation of unidimensionality. Examination of the principal components analysis did not provide support for unidimensionality. The item-person map illustrates poor targeting of items. CONCLUSIONS: Alcohol abuse and dependence criterion appear to reflect a unidimensional construct, a finding that supports a single latent construct or factor consistent with the DSM-5 diagnostic model.

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STUDY DESIGN: Cross-sectional. OBJECTIVE: To preliminarily evaluate the validity of an interview-based spinal cord injury (SCI) neuropathic pain screening instrument. SETTING: Six university-based SCI centers in the United States. METHODS: Clinician diagnoses of neuropathic pain (NP) and non-neuropathic pain subtypes were collected independently of descriptions of the pain characteristics provided by the persons with SCI by using the Spinal Cord Injury Pain Instrument (SCIPI); SCIPI information and physician diagnoses for 82 pain sites of which they were most confident were subsequently compared. RESULTS: Four of the SCIPI items correlated significantly with the NP subtype as determined by the clinician. The best cutoff score for identifying NP was an endorsement of two or more of these four items. Using this cutoff, sensitivity of the SCIPI was 78%, specificity was 73% and overall diagnostic accuracy was 76%. CONCLUSION: In this preliminary study, the SCIPI, which can be administered by a nonclinician, appears to have good sensitivity, specificity and diagnostic accuracy in a SCI population; it may have a role as a screening tool for NP after SCI. Further study is needed.

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OBJECTIVE: To examine the one-month prevalence and impact of substance abuse in a large community sample of persons with multiple sclerosis (MS). METHOD: Members of the Multiple Sclerosis Society of King County were surveyed by mail. This multifaceted health survey included questions pertaining to substance abuse. Seven hundred and thirty-nine out of 1374 potential participants (54%) returned the survey, while 708 reported a medically confirmed diagnosis of MS and provided sufficient data. RESULTS: Fourteen per cent of the sample screened positive for possible alcohol abuse or dependence, and 7.4% reported misusing illicit drugs or prescription medications within the previous month. Possible alcohol abuse and drug misuse were associated with younger age, less severe MS related disability and being employed, as well as greater self-reported depressive symptomatology. Most persons with alcohol problems indicated interest in learning more about ways to stop or cut down. CONCLUSIONS: Substance abuse may be present in up to 19% of this sample and contribute to high rates of depression. There may be greater risk of harm due to substance abuse in people with MS because of the potential magnification of motor and cognitive impairments. Comprehensive MS care should include substance abuse screening and advice to cut down or abstain.

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OBJECTIVE: To examine the reliability and validity of the Readiness to Change Questionnaire (RTC) among persons with recent traumatic brain injury. DESIGN: Survey. SETTING: Inpatient rehabilitation. PARTICIPANTS: One-hundred twenty-six persons with recent TBI. RESULTS: In the first step of the analyses the RTC measure was rescaled and shortened to produce a coherent linear measure of readiness to change. Subsequent analyses showed that the linear measure fit a three stage model of change and correlated in meaningful ways with independent measures of alcohol problem severity. CONCLUSIONS: The RTC measure can be substantially improved by utilizing results obtained from rating scale analysis. The resulting 10-item linear scale has good internal consistency, a theoretically sound factor structure and meaningful correlations with external variables. Measuring readiness to change may be useful for tailoring treatment and predicting outcomes, though more research is needed in this area.

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OBJECTIVE: To determine the potential relation between satisfaction with life after spinal cord injury and access to the environment as measured by selected items from the Craig Handicap Assessment and Reporting Technique (CHART). DESIGN: Prospective, correlational/predictive study using cross-sectional and longitudinal data from 18 Model Spinal Cord Injury Systems of Care. SUBJECTS: Adult persons with traumatic-onset spinal cord injury (n = 650) evaluated at 1 or 2 years postinjury. OUTCOME MEASURE: Satisfaction With Life Scale (SWLS). PREDICTOR VARIABLES: Demographic characteristics, impairment and disability classifications. medical complications, rehabilitation insurance status, occupational status as measured by the CHART Occupation Scale, self-perceived health (from SF-36), and access to the environment as measured by items from the CHART Mobility Scale. RESULTS: Access to the environment was positively and linearly associated with satisfaction with life, demonstrated both positive and negative change over time, and was positively associated with subject's neurologic status. Access to the environment added to the explanatory model to predict life satisfaction even after all other independent measures were accounted for. CONCLUSION: Access to the environment (an "outside the person" factor) is important in predicting satisfaction with life for persons with spinal cord injury. The measure of access to the environment developed here is promising and worthy of further exploration and expansion.

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Alcohol intoxication frequently contributes to the occurrence of traumatic brain injury. Few studies, however, have examined whether acute pre-injury alcohol intoxication or premorbid history of alcohol abuse exacerbate cognitive impairments that commonly result from traumatic brain injury. This study examined the influence of blood alcohol level at time of hospital admission on cognitive functioning during the post-acute stage of recovery from traumatic brain injury. After controlling for pre-injury history of alcohol abuse, hospital admission blood alcohol level was predictive of poorer delayed verbal memory, greater decrement in verbal memory over time, and poorer visuospatial functioning. Moreover, there were non-significant trends for higher blood alcohol levels to predict poorer performance on measures of immediate verbal memory and perseveration.

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STATEMENT OF PURPOSE: This archival study sought to clarify the relationship between admission blood alcohol level (BAL) after traumatic brain injury (TBI) and subsequent neuropsychological functioning. It was hypothesized that BAL would be positively correlated with impairment on basic neuropsychological tests and that this relation would weaken as time since TBI increased. METHODS: Fifty-eight patients were tested within 60 days of their TBI. Correlational analyses were used to test the relation between neuropsychological performance and admission BAL. RESULTS: As expected, BAL was unrelated to demographic variables or lag time between TBI and time of testing, Bivariate correlations showed that higher BAL predicted poorer performance on a broad range of neuropsychological tests. Patients tested less than 30 days after their TBI showed the strongest effects. CONCLUSIONS: Neuropsychological impairments detected 1-2 months after TBI may be affected by BAL at the time of hospital admission. The influence of BAL seems greatest during the first month post-injury, but may persist beyond 30 days in some areas of cognitive function. Blood alcohol at the time of injury may have a direct effect on cognitive functioning or may be a proxy for the effects of chronic alcohol use or abuse. Clinical implications are discussed.

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OBJECTIVE: To describe alcohol use and motivation to change drinking among persons with recent spinal cord injury (SCI). DESIGN: Survey SETTING: Acute inpatient rehabilitation program PATIENTS: Subjects were 58 patients with recent SCI assessed during inpatient rehabilitation. MAIN OUTCOME MEASURES: Short Michigan Alcoholism Screening Test (SMAST), Readiness to Change questionnaire (RTC), and alcohol use questions. RESULTS: Subjects were on average 39 years old, 88% were male, and 86% were Caucasian. Thirty-five percent of the total sample scored in the "alcoholic" range on the SMAST. Twenty-nine (50%) of the sample were considered "at-risk" drinkers. Of these, 6 (21%) were in the precontemplation phase, 13 (45%) were in the contemplation phase, and 10 (34%) were in the action phase with respect to modifying their drinking habits. Multivariate analyses indicated that a positive history of alcoholism and higher daily consumption were associated with greater readiness to change. CONCLUSIONS: Soon after SCI, most at-risk drinkers are at least considering changes in their alcohol use. This situation may represent an underutilized window of opportunity to implement interventions designed to reduce postinjury alcohol abuse and related impairments.

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The use of hypnosis for treating pain from severe burn injuries has received strong anecdotal support from case reports. Controlled studies provide less dramatic but empirically sound support for the use of hypnosis with this problem. The mechanisms behind hypnotic analgesia for burn pain are poorly understood with this patient population, as they are with pain in general. It is likely that, whatever the mechanisms are behind hypnotic pain analgesia, patients with burn injuries are more receptive to hypnosis than the general population. This article postulates some variables that may account for this enhanced receptivity, including motivation, hypnotizability, dissociation, and regression.

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OBJECTIVE: To describe how motivated are persons with recent traumatic brain injury (TBI) to change their alcohol drinking habits and what factors affect their motivation. DESIGN: Survey. SETTING: Acute inpatient rehabilitation program. PATIENTS: Subjects were 50 patients with recent TBI during inpatient rehabilitation. MAIN OUTCOME MEASURES: Readiness to Change (RTC) questionnaire, Michigan Alcoholism Screening Test (MAST), and alcohol use questions. RESULTS: Subjects were 36 years old; 86% were men. Eighty-four percent fell in the contemplation or action phases. Comparisons with a separate medical patient sample suggested that TBI may be associated with greater contemplation of change and greater readiness to take action to change alcohol use. Multivariate analyses indicated that within the TBI sample a positive history of alcoholism, alcohol involved in the accident, and higher daily consumption were associated with greater readiness to change (especially contemplation scores). CONCLUSIONS: Soon after TBI, drinkers frequently contemplate changing their alcohol use. This situation may represent an underutilized window of opportunity to reduce postinjury alcohol use and abuse. Motivational interviewing techniques seem well suited to facilitate change during this period.

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OBJECTIVES: Disabling chronic fatigue that does not meet criteria for chronic fatigue syndrome (CFS) or fibromyalgia (FM) is a condition thought to be associated with substantial disability and an apparently high use of health-care services. The authors compare patients who have chronic fatigue, CFS, FM, or CFS and FM together (CFS+FM) on employment status, self-reported disability, number of medical care visits, type of services obtained, and other diagnoses received. METHODS: The authors studied 402 patients from a university-based chronic fatigue clinic. All patients underwent an initial structured diagnostic assessment. One hundred forty-seven patients met case criteria for CFS, 28 for FM, 61 for CFS+FM, and 166 fell in the residual chronic fatigue group. Of these patients, 388 completed a follow-up questionnaire an average of 1.7 years later. Chi-squared tests and analysis of variance were used to compare groups on follow-up measures of health-care use and disability. RESULTS: Patients with chronic fatigue, CFS, FM, and CFS+FM were similar in terms of disability and health-care use, though those with CFS+FM were significantly more likely to be unemployed and to use more chiropractic and "other" provider services. Rates of unemployment ranged from 26% (chronic fatigue) to 51% (CFS+FM). Overall, patients reported a mean of 21 visits to a wide variety health-care providers during the previous year, with no significant differences between groups. CONCLUSIONS: Chronic fatigue, CFS, and FM are associated with considerable personal and occupational disability and low rates of employment. The potentially large economic burden of these disorders underscores the need for accurate estimates of direct and indirect costs, the relative contribution of individual factors to disability, and the need to develop targeted rehabilitation programs.

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BACKGROUND: There are few data on the natural history and prognosis of persons with chronic fatigue (CF) or CF syndrome (CFS). Therefore, we compared functional outcomes in patients with each condition and tested the validity of various prognostic indicators. METHODS: Four hundred forty-five (89%) of 498 consecutive referral patients were surveyed an average of 1.5 years after an initial evaluation. Data from the initial evaluation were used to predict outcomes. RESULTS: Sixty-four percent of all patients reported improvement, but only 2% reported complete resolution of symptoms. Patients initially diagnosed as having CFS reported greater symptom severity and lower level of functioning at follow-up than did patients with CF. Major depression predicted unemployment in the CF group. Older age, longer duration of illness, and a lifetime history of dysthymia predicted less improvement in the CF group. Current dysthymia predicted less improvement for the CFS group. CONCLUSIONS: The case definition of CFS according to the Centers for Disease Control and Prevention identifies chronically fatigued patients with poorer prognosis. In a tertiary care setting, recovery from CF or CFS is rare, but improvement is common. Prognostic indicators vary for the two groups, but the coexistence of dysthymia suggests poorer outcomes generally.

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Ways of Coping Checklist-Revised protocols gathered from 35 persons with spinal cord injuries on admission to an in-patient rehabilitation unit were cluster analysed using Ward's method. A two-cluster solution was produced reflecting patterns of coping similar to Lazarus und Folkman's (1984) emotion- and problem-focused dichotomy. These patterns of coping were validated against sets of demographic/medical and emotional adjustment/attribution variables gathered on discharge. Results showed that a group of subjects using emotion-focused coping styles reported greater ratings of depression. These subjects focused less on physical and therapy progress to promote positive feelings and focused more on thoughts about the accident. There was also a trend for physical setbacks to contribute to negative mood in these patients. This pattern was associated with having been readmitted to hospital. The clinical and research implications of the study are discussed.

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Cluster analysis of the MMPI has been utilized widely in the chronic low back pain literature to try to identify reliable patient subtypes predictive of treatment outcome. We extended this methodology to patients with heterogeneous chronic medical conditions by replicating prototypic MMPI cluster group profiles and by relating cluster groups to clinical baseline and outcome data. Subjects were two independent samples (n = 254 and n = 263) of chronically ill patients admitted to an inpatient medicine/psychiatry unit. Using a four-cluster solution, similar cluster profile groups were replicated in both samples. Consistent differences emerged between cluster groups on functional impairment, psychiatric diagnoses, depression, and psychosomatic symptoms. Cluster group membership also predicted changes in functional impairment and depression six months after treatment. Results are discussed in terms of similarities between chronic low back pain and chronic illness and tailoring treatment to different patient types.

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Severe burn injuries provide researchers with an opportunity to study the effects of painful but usually transient trauma on psychological functioning. To that end, this article presents a review of the 3 main areas of this body of literature: (a) premorbid characteristics of people who sustain severe burn injuries, (b) psychological reactions during hospitalization, and (c) long-term adjustment. The general implications of these studies are discussed and then used to illuminate the circumstances under which individuals suffer the most from this type of trauma, the effects of such injuries on personality function, and how meaningful units of measurements can be defined. Potential clinical applications are also described.

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There is evidence that adaptation to chronic illness may be affected by psychological factors, especially how patients appraise and cope with the stress of their illness. The purpose of the present study was to examine the relationship of stress appraisal and coping responses to multiple behavioral indices of illness adjustment among patients with diverse chronic medical conditions. One hundred and one patients admitted to a multidisciplinary medicine/psychiatry unit completed measures of functional impairment, depression, symptom severity, and the Ways of Coping Checklist--Revised. Hierarchical regression analyses indicated that emotion-focused coping was positively related to poor psychosocial adjustment and depression after controlling for physician rated disease severity. Appraising chronic illness as holding one back predicted greater emotion-focused coping responses and poorer adjustment to illness. The use of problem-focused coping strategies was generally unrelated to illness adjustment. These findings suggest the presence of an emotion-focused coping triad consisting of wishful thinking, self blame, and avoidance, all of which appear to be maladaptive strategies when coping with chronic medical conditions. Implications for coping skills training and the need for longitudinal research is discussed.

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