Alison M. Cogan PhD, OTR/L (she/her/hers)

Importance. Veterans with mild traumatic brain injury (mTBI) and associated symptoms are at risk for suicide. Postconcussive symptoms (PCS) may heighten risk for suicidal thoughts by limiting veterans’ participation.

Objective. To investigate whether participation mediates the relationship between PCS and suicidal ideation.

Design. Cross-sectional, exploratory design. Structural equation models were used to investigate whether participation mediated the relationship between PCS and suicidal ideation.

Setting. Community.

Participants. Veterans with mTBI (N = 145).

Outcomes and Measures. The Ohio State University TBI Identification Method was used to establish mTBI diagnosis. We identified latent variables for PCS and participation using the Neurobehavioral Symptom Inventory and select domains of the Medical Outcomes Study Short Form–36, respectively. We used the Beck Scale for Suicide Ideation to measure the presence of suicidal ideation.

Results. Participation mediated the relationship between PCS and the presence of suicidal ideation (odds ratio [OR] = 1.09, p = .011). More severe PCS were associated with lesser participation (β = –.86, p < .001); greater participation was associated with lower odds of suicidal ideation (OR = 0.92, p = .007).

Conclusions and Relevance. PCS may heighten risk for suicidal thoughts among veterans by limiting successful participation, a primary target of occupational therapy intervention. Thus, the results suggest that occupational therapy practitioners can play a substantial role in suicide prevention services for veterans with mTBI. Preventive services could mitigate suicide risk among veterans with mTBI by enabling sustained engagement in meaningful and health-promoting activity (e.g., reasons for living) and targeting PCS.

Keywords. post-concussion syndrome, traumatic brain injury, mild, veterans, suicidal behavior

Objective. To quantify the economic burden of all-cause health care resource utilization (HCRU) among adults with and without chronic vestibular impairment (CVI) after a mild traumatic brain injury (mTBI).

Design. Retrospective matched cohort study.

Setting. IQVIA Integrated Data Warehouse.

Participants. People with mTBI+CVI (n=20,441) matched on baseline age, sex, year of mTBI event, and Charlson Comorbidity Index (CCI) score to people with mTBI only (n=20,441) (N=40,882).

Interventions. Not applicable.

Main Outcome Measures. All-cause health HCRU and costs at 12 and 24 months post mTBI diagnosis.

Results. People with mTBI+CVI had significantly higher all-cause HCRU and costs at both time points than those with mTBI only. Multivariable regression analysis showed that, when controlling for baseline variables, costs of care were 1.5 times higher for mTBI+CVI than mTBI only.

Conclusions. People who developed CVI after mTBI had greater overall HCRU and costs for up to 2 years after the injury event compared with people who did not develop CVI after controlling for age, sex, region, and CCI score. Further research on access to follow-up services and effectiveness of interventions to address CVI is warranted.

Keywords. Brain concussion; Costs and cost analysis; Health care costs; Postural balance; Rehabilitation

Objective. To evaluate the structural validity of the Mayo-Portland Adaptability Inventory Participation Index (M2PI) in a sample of veterans and to assess whether the tool functioned similarly for male and female veterans.

Design. Rasch analysis of M2PI records from the National Veterans Traumatic Brain Injury Health Registry database from 2012-2018.

Setting. National VA Polytrauma System of Care outpatient settings.

Participants. Veterans with a clinically confirmed history of traumatic brain injury (TBI) (N=6065; 94% male).

Interventions. Not applicable.

Main Outcome Measures. M2PI, a 5-point Likert-type scale with 8 items. For this analysis, the 2 employment items were treated individually for a total of 9 items.

Results. The employment items misfit the Rasch Measurement model (paid employment mean square [MnSq]=1.40; other employment MnSq=1.34) and were removed from subsequent iterations. The final model had eigenvalue 1.87 on the first contrast, suggesting unidimensionality of the remaining 7 items. Item order from least to most participation restriction was transportation, self-care, residence management, financial management, initiation, leisure, and social contact. Wright's person separation reliability for nonnormal distributions was 0.93, indicating appropriateness of M2PI for making individual-level treatment decisions. Mean person measure was −0.92±1.34 logits, suggesting that participants did not report restrictions on most items (item mean=0 logits). A total of 3.8% of the sample had the minimum score (no impairment on all items), and 0.2% had the maximum score. Four items had different item calibrations (≥0.25 logits) for female compared with male veterans, but the hierarchy of items was unchanged when the female sample was examined separately.

Conclusions. These findings suggest that, although employment is a poor indicator of participation restrictions among veterans with TBI, the M2PI is unidimensional. Because of subtle differences in scale function between male and female participants, M2PI should be part of a more thorough clinical interview about participation strengths and restrictions.

Keywords. Brain injuries, traumatic; Community participation; Psychometrics; Rehabilitation; Veterans

In this paper, we explore how socially constructed hegemonic masculinity permeates military culture, and how this cultural context intersects with the seeking and receiving of health care by active-duty US military service members with chronic mild traumatic brain injury (mTBI) (n = 18). Data were collected through individual interviews and focus groups. Using Bourdieu’s theory of practice as an analytical framework, we identified four themes: maintenance of social capital, remaining in the field, reframing health care use to bolster social capital, and risk of health care use as not being rewarded. Each emerged from statements about why participants had avoided seeking health care for physical and psychological needs during their military service. We consider our findings in the context of maintaining status within an institutional steeped in hegemonic masculinity and describe implications for reframing caring for the body and dealing with problems as masculine acts.

Keywords. mild traumatic brain injury, military personnel, culture, masculinity

Objectives. To explore the association between therapy minutes per length of stay (LOS) day (TMLD), functional outcomes, and rate of functional recovery among older adults after elective hip or knee replacement surgery across postacute (PAC) settings.

Design. Secondary analysis of data collected for an observational cohort study from 2005 to 2010.

Setting. Four inpatient rehabilitation facilities (IRF) and 7 skilled nursing facilities (SNF).

Participants. Adults aged 65 years or older (N=162) with Medicare fee-for-service insurance and a primary diagnosis of elective hip or knee replacement.

Interventions. Not applicable.

Main Outcome Measures. FIM mobility and self-care measures at discharge.

Results. The TMLD was divided into high, medium, and low categories. Participants were grouped into low, medium, and high gain rate groups based on their average change in mobility and self-care FIM measures per LOS day. Gain rate and TMLD groups were crossmapped to create 9 gain-TMLD groups separately for mobility and self-care. There were no significant differences in admission mobility or self-care measures by gain rate and TMLD trajectory or by facility type (IRF or SNF). TMLD was not significantly associated with discharge mobility measures. Participants in high gain trajectories attained independence with mobility and self-care tasks at discharge regardless of TMLD. Those in low gain trajectories needed supervision or assistance on all mobility tasks. Older age and greater pain at discharge were significantly associated with lower odds of being in the medium or high gain rate groups.

Conclusions. For clinicians and facility managers who must care for patients with constrained resources, the shift to value-based reimbursement for rehabilitation services in PAC settings has reinvigorated the question of whether the duration of therapy provided influences patient outcomes. Three hours of daily therapy after joint replacement surgery may exceed what is necessary for recovery. Postsurgical pain management remains a significant challenge in older adults.

Keywords. Arthroplasty; Geriatrics; Pain management; Rehabilitation

Objectives. Cognitive impairment is highly prevalent after stroke, with 77% of people having impairment in at least 2 cognitive domains. The purpose of this study is to describe the association between therapy minutes per length of stay (LOS) day and cognitive recovery in patients receiving rehabilitation services in inpatient post-acute care facilities following a stroke.

Design. Secondary analyses of data collected in inpatient rehabilitation and skilled nursing facilities from 2005 to 2010 for an observational cohort study.

Setting and Participants. Participants were adults aged ≥65 years with Medicare insurance and primary diagnosis of stroke (N = 100). Participants who met criteria for dementia (n = 5) were excluded from analyses. We calculated therapy minutes per LOS day for occupational therapy, physical therapy, speech-language pathology, and all therapies combined; therapy times were dichotomized into high or low minutes per LOS day (MLD). We used an ordinary least squares regression model for cognitive outcome at discharge to control for cognitive status at admission, therapy intensity by discipline, and LOS.

Results. At baseline, participants were classified as having severe (n = 11), moderate (n = 39), or mild (n = 45) cognitive impairment. Impairment groups were not significantly different on any demographic variables. The adjusted regression model showed that high occupational therapy MLD (>50 minutes per LOS day) (P = .028) was significantly associated with cognitive measure at discharge compared with low occupational therapy MLD when controlling for cognitive impairment group at baseline (P < .001). Neither high physical therapy MLD nor speech-language pathology MLD was significantly associated with cognitive outcome relative to their respective low TMLD groups.

Conclusions and Implications. Our results show that higher-intensity occupational therapy services were associated with better cognitive outcome at discharge from inpatient rehabilitation after stroke. Findings also suggest that volume of therapy alone does not necessarily produce optimal outcomes. Both amount and type of therapy should be tailored to meet the needs of individual patients.

Keywords. Rehabilitation; cognition; cognitive dysfunction; stroke; occupational therapy; post-acute care

Objective. To combine items from the Functional Independence Measure, Minimum Data Set (MDS) 2.0, and the Outcome and Assessment Information Set (OASIS)-B to reliably measure cognition across postacute care settings and facilitate future studies of patient cognitive recovery.

Design. Rasch analysis of data from a prospective, observational cohort study.

Setting. Postacute care inclusive of inpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.

Participants. Patients (N=147) receiving rehabilitation services.

Interventions. Not applicable.

Main Outcome Measures. Functional Independence Measure, MDS 2.0, and the OASIS-B.

Results. Six cognition items demonstrated good construct validity with no misfitting items, unidimensionality, good precision (person separation reliability, 0.95), and an item hierarchy that reflected a clinically meaningful continuum of cognitive challenge.

Conclusions. This is the first attempt to combine the cognition items from the 3 historically, federally mandated assessments to create a common metric for cognition. These 6 items could be adopted as standardized patient assessment data elements to improve cognitive assessment across postacute care settings.

Keywords. Cognition; Outcome measures; Rehabilitation; Stroke; Subacute care

Objectives. To identify areas of most restricted self-reported participation among veterans with traumatic brain injury (TBI), explore associations among participation restriction and clinical characteristics, and examine differences in participation restrictions by sex.

Design. Retrospective cross-sectional design.

Setting. National VA Polytrauma System of Care outpatient settings.

Participants. Veterans with a confirmed TBI event (N=6065).

Interventions. Not applicable.

Main Outcome Measure(s). Mayo-Portland Participation Index (M2PI), a 5-point Likert-type scale with 8 items. Total score was converted to standardized T score for analysis.

Results. The sample consisted of 5679 male and 386 female veterans with ≥1 clinically confirmed TBI events (69% white; 74% with blast exposure). The M2PI items with greatest perceived restrictions were social contact, leisure, and initiation. There were no significant differences between men and women on M2PI standardized T scores. Wilcoxon rank-sum analyses showed significant differences by sex on 4 items: leisure, residence, employment, and financial management (all P<.01). In multinomial logistic regression on each item controlling for demographics, injury characteristics, and comorbidities, female veterans had significantly greater relative risk for part-time work and unemployment on the employment item and significantly less risk for impairment on the residence and financial management item.

Conclusions. There was no significant difference between men and women. Veterans on M2PI standardized T scores, which masks differences in response patterns to individual items. Clinical teams should be encouraged to discuss perceived restrictions with patients and target these areas in treatment planning. Future work is needed to investigate the psychometric properties of the M2PI by biological sex.

This scoping study describes the range of outcomes in traumatic brain injury (TBI) studies of military service members and veterans addressing gender differences. A secondary purpose is to identify differences in outcomes between male and female participants in such studies. We searched PubMed, CiNAHL, and PsycInfo databases for relevant articles. Two reviewers independently screened results. Of 822 unique titles and abstracts screened for eligibility, 55 full articles were reviewed, with 29 studies meeting full inclusion criteria. Twenty of the 29 included studies used retrospective designs and all but two used data collected from Veterans Affairs or Department of Defense health care settings. TBI was diagnosed by self-report, screening, and evaluation procedures, and medical record documentation. Ten different outcome categories were identified among the included studies. In general, female service members and veterans have not been well represented in TBI outcomes research. Evidence suggests that female veterans with mild TBI (mTBI) report more neurobehavioral symptoms and use more outpatient services than male veterans. Studies also indicate that female veterans with TBI are more frequently diagnosed with depression. Additional research is essential to support precision treatment recommendations for female veterans with TBI, as women represent a growing proportion of the patients served by the Veterans Health Administration.

Importance. Medicare is shifting from payment for postacute care services based on the volume provided to payment based on value as determined by patient characteristics and functional outcomes. Matching therapy time and length of stay (LOS) to patient needs will be critical to optimize functional outcomes and manage costs.

Objective. To investigate the association among therapy time, LOS, and functional outcomes for patients following hip fracture surgery.

Design, Setting, and Participants. This retrospective cohort study analyzed data on patients from 4 inpatient rehabilitation facilities and 7 skilled nursing facilities in the eastern and midwestern United States. Participants were patients aged 65 years or older who received inpatient rehabilitation services for hip fracture and had Medicare fee-for-service as their primary payer. Data were collected from 2005 to 2010. Analysis was conducted from November 2018 to June 2019.

Exposure. Therapy minutes per LOS day.

Main Outcomes and Measures. Functional Independence Measure mobility and self-care measures at discharge. Patients were categorized into 9 recovery groups based on low, medium, or high therapy minutes per LOS day and low, medium, or high rate of functional gain per day.

Results. A total of 150 patients (101 [67.3%] female; 148 [98.6%] white; mean [SD] age, 82.0 [7.3] years) met inclusion criteria. Participants in all gain and therapy minutes per LOS day trajectories were similar in function at rehabilitation admission (mean [SD] mobility, 16.2 [3.2]; F_8,141 = 1.26; P = .27) but differed significantly at discharge (mean [SD] mobility, 23.9 [5.2]; F_8,141 = 14.34; P < .001). High-gain patients achieved mobility independence by discharge; low-gain patients needed assistance on nearly all mobility tasks. Medium-gain patients with a mean LOS of 27 days were independent in mobility at discharge; those with a mean LOS less than 21 days needed supervision with toilet transfers and were dependent with stairs. Length of stay and functional gain rate explained much of the variance in mobility and self-care scores at discharge. Although medium– and high–therapy minutes per LOS day groups were statistically significant in the regression model (β = 6.99; P = .001; and β = 11.46; P = .007, respectively), they explained only 1% of the variance in discharge outcome. Marginal means suggest that medium-gain patients with shorter LOS would have achieved mobility independence if LOS had been extended.

Conclusions and Relevance. In this study, rate of recovery and LOS in skilled nursing and inpatient rehabilitation facilities were associated with mobility and self-care outcomes at discharge following hip fracture surgery, particularly for medium-gain patients. Therapy time per day explained only 1% of the variance in discharge outcome. Discharging medium-gain patients before 21 days LOS may transfer burden of care to family and caregivers, home health, and outpatient services.

Purpose. Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.

Methods. This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.

Results and conclusions. Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention’s reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.

Keywords. Spinal cord injuries, pressure injury, lifestyle, intervention, cultural diversity

A growing number of individuals are living with chronic traumatic brain injury. As these individuals and their families attempt to reintegrate into their communities, several ethical questions arise for clinicians and researchers. These include issues around alignment of perspectives and priorities, as well as responsibilities for ongoing treatment, education, community outreach, and research. An action plan for addressing these questions is outlined.

The purpose of this study is to describe important features of occupational therapy practice for treatment of military service members with chronic symptoms and a history of mild traumatic brain injury (mTBI) in a military concussion care clinic from service members’ perspectives with support from occupational therapy practitioners. Two series of focus groups were conducted with service members with chronic mTBI-related symptoms (n = 6) and practitioners (n = 5). Data were analyzed concurrently with collection. We identified five main themes: therapeutic relationship, consistent inclusion of family members, combat versus noncombat injuries, loss of military identity, and assessment against population norms. The findings of this study suggest that service members’ evaluations of occupational therapy are based on the overall experience of the encounter, centered by the therapeutic relationship, rather than specific intervention strategies or technology.

Keywords. brain injury, occupational therapy, qualitative research, veterans, client-centered practice

Importance. Pregnancy loss and infant death are unexpected, traumatic, life-changing events. The role of occupational therapy practitioners in treating this population is not well defined.

Objective. To describe the outcomes of an occupation-based residential retreat for women who have experienced pregnancy or infant loss.

Design. Program evaluation.

Setting. Seven residential retreats for bereaved mothers.

Participants. One hundred forty-one women who experienced perinatal loss.

Intervention. Residential retreats that were held in natural settings and included occupation-based activities such as group discussions, yoga, meditation, crafts, and rituals to facilitate grieving and healing processes after perinatal loss.

Outcomes and Measures. The Beck Depression Inventory, PTSD Checklist–Civilian Version, Self-Compassion Scale, and Multidimensional Scale of Perceived Social Support were collected pre- and postretreat.

Results. Statistically significant improvements were seen in women’s depression, trauma, self-compassion, and perceived social support from pre- to postretreat.

Conclusions and Relevance. At present, occupational therapy practitioners support this population primarily by providing referrals and information about local resources. However, as occupational therapy practice in primary care settings grows, so too do possibilities for the development of occupational therapy–related interventions to support maternal mental health.

What This Article Adds. This article provides preliminary support for occupation-based retreats as a treatment for improving maternal mental health after perinatal loss.

Keywords. depressive disorders, infant, infant death, pregnancy, pregnancy loss, mental health, perinatal period, wounds and injuries, compassion, child

Objective. The purpose of this study was to identify the needs of military service members with chronic symptoms after mild traumatic brain injury (mTBI) that fall within the scope of occupational therapy practice.

Method. In this qualitative descriptive study, service members with a history of mTBI (N = 12) participated in semistructured interviews about their injury history, symptoms, daily routines, challenges, and plans.

Results. Two main themes were identified: occupational changes and plans for the future. Occupational changes contains six subthemes: (1) rest and sleep, (2) activities of daily living and instrumental activities of daily living, (3) work, (4) social participation, (5) play and leisure, and (6) education. Plans for the future contains three subthemes: (1) supports, (2) barriers, and (3) fears.

Conclusion. Occupational therapists who work with this population should consider all areas of occupation, especially sleep, during assessment and treatment planning. Some clients may require additional support for preparing for civilian life.

Background. Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI).

Objective. To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI.

Methods. A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program.

Results. Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities.

Conclusions. Some protective factors (e.g., personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

Context/Objective. Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

Design. A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

Setting. Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

Participants. Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

Interventions. The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

Outcome Measures. Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

Results. Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

Conclusions. Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

Trial Registration. ClinicalTrials.gov NCT01999816.

Purpose. Participation is widely recognized as an important outcome for rehabilitation. However, it lacks a universally accepted definition. The purpose of this review is to synthesize the literature about participation in rehabilitation in order to clarify the term and increase its usefulness for rehabilitation providers and researchers.

Methods. We undertook an interpretive synthesis of the literature, drawing from a broad and varied selection of the vast number of publications on the subject of participation. The search and analysis was iterative and continued until saturation of themes was achieved.

Results and Conclusions. Seventy-six articles were included in our analysis. We argue that three essential dimensions — performance, subjective experience, and interpersonal connection — constitute participation. We further divide participation into community-based and interventional contexts. Interventional participation is circumscribed by the treatment setting, whereas community-based encompasses all other areas. Participation in either interventional or community-based contexts is largely determined by the available opportunities from which a person can choose, with such opportunities affected by conditions that are either internal or external to the individual. As defined in this framework, participation is not inherently good or bad; rather, its effect is determined by a person's unique life circumstances and the impact may not always be apparent. We posit this model as a resource for future research as well as clinical reasoning.

Implications for Rehabilitation. The often tacit assumption that increasing participation is a desirable outcome needs to be challenged and considered in each patient's life situation. Treatment settings constitute a unique context in which patients participate. Intervention goals should be clearly connected with patients' personal goals for community-based participation.

Rehabilitation practice aims to restore people to health after injury or illness. Health involves not only managing the technical aspects of treating the condition, but also living a good and personally fulfilling life. In addition to biomedical management, attention to flourishing – or fulfillment of one’s potential – requires intentional and individualized intervention. Clinicians can use narrative to better understand patient needs and values to encourage such a patient-centered approach to care. The purpose of this article is to describe the benefits of developing skills for understanding and interpreting stories, i.e. “narrative competence”, through reading and analyzing published first-person illness narratives. I will illustrate this approach by examining a story about a journey excerpted from memoirs written by a patient and caregiver dyad; then, contrasting between biomedical and narrative analyses of the story, demonstrate how the latter can enhance clinical reasoning for rehabilitation practice. This approach has the potential to generate new skills for rehabilitation clinicians that can help all patients flourish, regardless of disability.

Keywords. Narrative, patient-centered care, competencies, clinical reasoning

Mild traumatic brain injury (mTBI) has been labeled the “signature injury” of the wars in Iraq and Afghanistan, and approximately half of mTBIs that occur in combat are due to explosive blasts. The rapid change in pressure that results from an explosion may make blast injury distinct from mTBI due to other causes. Persistent symptoms following blast mTBI may be related to white matter damage that has recently been identified using innovative neuroimaging techniques, such as diffusion tensor imaging (DTI). By comparing the DTI findings in blast mTBI to studies of the effects of white matter structure on functional performance, hypotheses can be developed about the implications of the injury for engagement in occupation. Incorporation of neuroscience evidence about the effects of blast mTBI may provide objective evidence of underlying damage that correlates with deficits in occupational engagement of military service members and veterans who are affected by these injuries.

Keywords. neuroscience; mild traumatic brain injury; military; veterans; occupation; diffusion tensor imaging; white matter

Objective. To investigate the efficacy of behavioral or educational interventions in preventing pressure ulcers in community-dwelling adults with spinal cord injury (SCI).

Data Sources. Cochrane, Clinical Trials, PubMed, and Web of Science were searched in June 2016. The search combined related terms for pressure ulcers, spinal cord injury, and behavioral intervention. Each database was searched from its inception with no restrictions on year of publication.

Review Methods. Inclusion criteria required that articles were (a) published in a peer-reviewed journal in English, (b) evaluated a behavioral or educational intervention for pressure ulcer prevention, (c) included community-dwelling adult participants aged 18 years and older with SCI, (d) measured pressure ulcer occurrence, recurrence, or skin breakdown as an outcome, and (e) had a minimum of 10 participants. All study designs were considered. Two reviewers independently screened titles and abstracts. Extracted information included study design, sample size, description of the intervention and control condition, pressure ulcer outcome measures, and corresponding results.

Results. The search strategy yielded 444 unique articles of which five met inclusion criteria. Three were randomized trials and two were quasi-experimental designs. A total of 513 participants were represented. The method of pressure ulcer or skin breakdown measurement varied widely among studies. Results on pressure ulcer outcomes were null in all studies. Considerable methodological problems with recruitment, intervention fidelity, and participant adherence were reported.

Conclusions. At present, there is no positive evidence to support the efficacy of behavioral or educational interventions in preventing pressure ulcer occurrence in adults with SCI.

This paper argues the benefits of characterizing occupational transitions as movement between figured worlds, which are socially constructed units that are characterized by particular people and activities, and that shape identities. Further, positive withdrawal, which is a purposeful decision to limit participation when the requirements of engaging surpass self-perceived ability, describes limited engagement with a figured world. To illustrate the utility of this lens, the community reintegration of military service members as they finish deployment and return to family and community life is explored. The figured worlds of military and family are drawn from first person accounts of deployment and reintegration experiences from the perspectives of both service members and spouses. The constructs of figured world and positive withdrawal are found to be useful ways to describe community reintegration for both service members and families and the complex shifts in identity associated with the transition process. The framework presented expands on the occupational science literature by presenting a framework for non-linear, bidirectional occupational transitions in which individuals return to familiar settings rather than enter novel ones. The constructs of figured world and positive withdrawal can contribute to future theory development and research with populations that experience similar occupational transitions.

Keywords. community reintegration; figured world; military life; occupational transition; daily routines

Reorganized, expanded, and updated, this new edition of the award-winning Lifestyle Redesign gives practical guidance in this preventative occupational therapy program for independent-living older adults. The work integrates the concept of the USC's landmark Well Elderly Studies, which determined that preventive occupational therapy greatly enhances the health and quality of life of independent-living older adults.

Twelve modules, including those on longevity, stress, home safety and navigating health care, illustrate how to incorporate the program into practice. Includes a flash drive with program handouts.

Implementation into real-world practice of interventions previously studied in randomized controlled trials is an ongoing challenge. In this article, we describe the methodology we used for the first phase of a project for the implementation and outcomes assessment of an occupational therapy pressure ulcer prevention intervention for people with spinal cord injury in the Veterans Health Administration. This first phase of the project was guided by practice-based evidence research methodology and resulted in an intervention manual tailored to meet the needs of Veterans and the establishment of a system for documenting and monitoring care processes, patient characteristics, and intervention outcomes. This system, in turn, will provide the data-gathering template for the next phase in which the beneficial effects of the intervention will be assessed. We conclude by recommending that clinicians explore the utility of this approach for the implementation of other novel interventions.

More than 2 million U.S. military servicemembers have deployed to Afghanistan or Iraq since September 11, 2001. Unlike during prior conflicts, many servicemembers leave spouses and children behind. Long, multiple deployments cause strain on family at home, with new challenges arising when servicemembers return from combat and reintegrate into family and civilian life. In World Wars I and II, occupational therapy practitioners played a significant role in supporting servicemember reintegration. However, their presence in program delivery in this practice area is limited. Occupational therapy researchers and practitioners can make a valuable contribution by helping families tailor daily activities and routines to address challenges and optimize health and wellness. However, barriers such as reimbursement for services, workforce availability, and access to military families have limited the profession’s full engagement. Advocacy is needed to help establish occupational therapy as a key component of the mental and preventive health care teams serving military servicemembers.

Keywords. mental health, military personnel, prevention, child, preventive health services

Mild traumatic brain injury (mTBI), also known as concussion, has been labeled the “signature injury” of the wars in Iraq and Afghanistan. A subset of military personnel with mTBI experience ongoing symptoms well beyond the normal recovery window. While much research has been dedicated to understanding the etiology and severity of the symptoms, very little has assessed how long-term symptoms impact participation in daily life. A scoping study of the occupational science and occupational therapy literature was conducted to ascertain the current state of research on the impact of mTBI on participation in daily life activities, as well as occupational therapy interventions for mTBI. Although the emphasis in this article is on military personnel with mTBI, studies on civilians with mTBI were included in the review as research with military populations is extremely limited. Based on the literature reviewed, the author suggests a role for occupational science research and occupational therapy practice in meeting the occupational needs of military service members with persistent symptoms after mTBI.

Keywords. mild traumatic brain injury, concussion, military personnel