Physical functioning and mental health treatment initiation and retention for veterans with posttraumatic stress disorder: a prospective cohort study

Background Most US adults with posttraumatic stress disorder (PTSD) do not initiate mental health treatment within a year of diagnosis. Increasing treatment uptake can improve health and quality of life for those with PTSD. Individuals with PTSD are more likely to report poor physical functioning, which may contribute to difficulty with treatment initiation and retention. We sought to determine the effects of poor physical functioning on mental health treatment initiation and retention for individuals with PTSD. Methods We used data for a national cohort of veterans in VA care; diagnosed with PTSD in June 2008-July 2009; with no mental health treatment in the prior year; and who responded to baseline surveys on physical functioning and PTSD symptoms (n = 6,765). Physical functioning was assessed using Veterans RAND 12-item Short Form Health Survey, and encoded as limitations in physical functioning and role limitations due to physical health. Treatment initiation (within 6 months of diagnosis) was determined using VA data and categorized as none (reference), only medications, only psychotherapy, or both. Treatment retention was defined as having ≥ 4 months of appropriate antidepressant or ≥ 8 psychotherapy encounters. Results In multinomial models, greater limitations in physical functioning were associated with lower odds of initiating only psychotherapy (OR 0.82 [95 % CI 0.68, 0.97] for limited a little and OR 0.74 [0.61, 0.90] for limited a lot, compared to reference “Not limited at all”). However, it was not associated with initiation of medications alone (OR 1.04 [0.85, 1.28] for limited a little and OR 1.07 [0.86, 1.34] for limited a lot) or combined with psychotherapy (OR 1.03 [0.85, 1.25] for limited a little and OR 0.95 [0.78, 1.17] for limited a lot). Greater limitations in physical functioning were also associated with lower odds of psychotherapy retention (OR 0.69 [0.53, 0.89] for limited a lot) but not for medications (e.g., OR 0.96 [0.79, 1.17] for limited a lot). Role limitations was only associated with initiation of both medications and psychotherapy, but there was no effect gradient (OR 1.38 [1.03, 1.86] for limitations a little or some of the time, and OR 1.18 [0.63, 1.06] for most or all of the time, compared to reference “None of the time”). Accounting for chronic physical health conditions did not attenuate associations between limitations in physical functioning (or role limitations) and PTSD treatment; having more chronic conditions was associated with lower odds of both initiation and retention for all treatments (e.g., for 2 + conditions OR 0.53 [0.41, 0.67] for initiation of psychotherapy). Conclusions Greater limitations in physical functioning may be a barrier to psychotherapy initiation and retention. Future interventions addressing physical functioning may enhance uptake of psychotherapy.

Markedly poor physical functioning status of people experiencing homelessness admitted to an acute hospital setting

Adults who are homeless experience poor health and frequently require hospital in-patient care but the physical functioning ability of this group is rarely considered. The objective of this study was to evaluate a broad range of physical functioning variables to enable better future planning of targeted health and accommodation services for this group. This cross-sectional, observational study was conducted in a large acute hospital in Dublin, Ireland. A comprehensive ward-based test battery evaluated physical functioning in 65 in-patients registered as homeless with an age range of 23–80 years. Less than 10% (n = 5) were > 70 years. 58/65 (83%) of participants had mobility limitations and 35/65 (54%) reported at least one fall in the previous six months. Only 25/66 (35%) were able to walk for 6 min and 20/65 (31%) were able to climb one flight of stairs. 45/63 (70%) of participants were pre-frail or frail. Muscular mass was normal in the majority of participants but grip strength was low. This study revealed hospital in-patients registered as homeless displayed particularly poor physical functioning levels and mobility regardless of age. Health and housing services should address the unmet physical functioning needs of this vulnerable group.

A modified Gritti-Stokes amputation technique as a solution for recurring aseptic loosening of a knee arthroplasty: A single-patient case study

Case Description: A 56-year-old man with persistent knee pain and poor physical functioning due to recurring loosening of a (revised) total knee arthroplasty, was treated with a modified Gritti-Stokes amputation. Objectives: to describe the modified Gritti-Stokes amputation technique as an ultimate therapy for failed total knee arthroplasty and to assess the functional outcome for one patient 1 year post-surgery. Study design: a single patient case study. Treatment: a modified Gritti-Stokes amputation, with removal of the overlying cartilage and subchondral surfaces of both the patella and femur after removing the total knee arthroplasty. Outcomes: After rehabilitation, the patient has a fully end-bearing residual limb, is able to walk without pain (with a prosthesis) and perform his daily activities. Conclusions: In cases of recurring loosening of a (revised) total knee arthroplasty, a modified Gritti-Stokes amputation can create an end-bearing residual limb without pain and with good functional outcome.

BIRTHWEIGHT, LIFETIME OBESITY, AND PHYSICAL FUNCTIONING IN MID-ADULTHOOD: A NATIONWIDE BIRTH COHORT STUDY

Evidence is scant on long-term implications of body mass index (BMI) gains over the life-course for poor physical functioning (PF). Using the 1958 British birth cohort (N=8,674) we examine whether i) birthweight and BMI across the life-course; ii) BMI gains at specific life-stages; and iii) age of obesity onset, were associated with PF at 50y. At each adult age, obesity was associated with poor PF (e.g. for males at 23y adjusted-ORs for poor PF was 2.28(1.34,3.91)). BMI gains were associated with poor PF (e.g. for females, adjusted-OR per SD BMI gain 16-23y was 1.28(1.13,1.46)). Longer obesity duration was associated with poor PF (e.g. for males, adjusted-OR was 2.32(1.26,4.29) for childhood obesity onset, and 1.50(1.16,1.96) for mid-adulthood onset); associations were abolished with further adjustment for 50y BMI. Obesity, BMI gains, and earlier obesity onset were associated with poor PF in mid-adulthood reinforcing the importance of preventing obesity early in the lifecourse.

Factors associated with impaired physical functioning and mental health in working-age patients attending a post–intensive care follow-up clinic three months after hospital discharge

Patients recovering from critical illness are often suffering from remarkable limitations in their everyday life. The purpose of this study was to find factors associated with poor physical functioning and mental health after critical illness. The study was conducted among patients who met the inclusion criteria of our post–intensive care unit follow-up clinic. The patients were invited to the follow-up clinic three months after hospital discharge. The participants filled out a RAND-36 questionnaire, underwent a clinical examination and were stratified to those with good or poor recovery according to physical functioning and emotional wellbeing. Altogether 332 out of 351 follow-up clinic attendees had data available for analysis. In physical functioning 40% of patients achieved a poor outcome. In mental health the percentage was 8%. The patients with poor physical functioning had a longer hospital stay and were more likely to have received vasopressors. Eleven out of 16 (69%) multitrauma patients had poor physical functioning. Patients with poor physical functioning had more memories of pain, achieved worse results in a six-minute walk test and were less likely to be able to move independently. The patients with poor mental health had higher delirium incidence and fewer memories of relatives’ visits and of nurses. The conclusions of this study were that the memories of pain, multitrauma and longer hospital stay were associated with a poor physical functioning outcome. Delirium and a lack of memories of relatives and nurses were associated with a poor mental health outcome.

Child maltreatment as a predictor of adult physical functioning in a prospective British birth cohort

ObjectiveChild maltreatment (abuse and neglect) has established associations with mental health; however, little is known about its relationship with physical functioning. Physical functioning (ie, the ability to perform the physical tasks of daily living) in adulthood is an important outcome to consider, as it is strongly associated with an individual’s ability to work, and future disability and dependency. We aimed to establish whether maltreatment was associated with physical functioning, independent of other early-life factors.Setting1958 British birth cohort.Participants8150 males and females with data on abuse and who participated at age 50 years.Outcome measuresThe primary outcome was poor physical functioning at 50 years (<65 on the Short-Form 36 survey physical functioning subscale). Secondary outcomes included mental health and self-reported health at 50 years.Results23% of participants reported at least one type of maltreatment; 12% were identified with poor physical functioning. Neglect (ORadj1.55, 95% CI 1.24 to 1.93), psychological abuse (ORadj1.49, 1.17–1.88) and sexual abuse (ORadj2.56, 1.66–3.96) were associated with poor physical functioning independent of other maltreatments and covariates, including childhood social class, birth weight and childhood illness. Odds of poor physical functioning increased with multiple types of maltreatment (ptrend<0.001); ORadjranged from 1.49 (1.23–1.82) for a single type to 2.09 (1.53–2.87) for those reporting>3 types of maltreatment, compared with those with none. Associations of similar magnitude were observed for mental and self-reported health outcomes.ConclusionsChild neglect, psychological and sexual abuse were associated with poor physical functioning at 50 years, with accumulating risk for those with multiple types of maltreatment. Associations were independent of numerous early-life factors and were comparable in magnitude to those observed for mental health and self-rated health. Prevention or alleviation of the ill effects of maltreatment could be an effective policy intervention to promote healthy ageing.