Warren T. Jackson Ph.D.

Armstrong, T. W., M. L. C. Williamson, T. R. Elliott, W. T. Jackson, N. T. Kearns and T. Ryan (2019). “Psychological distress among persons with upper extremity limb loss.” Br J Health Psychol 24(4): 746-763.

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OBJECTIVE: We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL). DESIGN: A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States. METHODS: Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects. RESULTS: Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress. CONCLUSIONS: These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference’s contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

Armstrong, T. W., M. L. C. Williamson, T. R. Elliott, W. T. Jackson, N. T. Kearns and T. Ryan (2019). “Psychological distress among persons with upper extremity limb loss.” Br J Health Psychol Apr 3. [Epub ahead of print].

Full text of this article.

OBJECTIVE: We examined predictors of clinically significant levels of psychological distress among individuals with upper limb loss (ULL). DESIGN: A multisite, cross-sectional study completed at six prosthetic rehabilitation centres throughout the United States. METHODS: Oral administration of a brief assessment battery to 307 participants with ULL including demographic variables, injury information, screening instruments for PTSD and depression, pain interference, and activity restriction measures. Hierarchical multinomial logit models were conducted. Outcome groups were created using recommended cut-off scores on brief screening measures of depression and PTSD. Final models were assessed including relative risk ratios and marginal effects. RESULTS: Over half of the sample screened positive for depression, PTSD, or both. Eight individuals exceeded the recommended cut-off score indicative of PTSD only (2.6%), and 106 participants (34.5%) screened positive for depression only. Moreover, 64 participants (20.8%) reported co-occurring PTSD and depression. Subsequent models revealed women and ethnic minority participants were more likely to have clinically significant levels of depression and PTSD. Greater restriction in activity and increased pain interference also predicted psychological distress. CONCLUSIONS: These findings indicate a significant number of individuals with ULL experience clinically significant levels of psychological distress, and routine clinical assessment of depression and PTSD is warranted. Women and individuals from ethnic minorities may be particularly at risk, regardless of the severity and cause of ULL. Restrictions in preferred and goal-directed activities and persistent pain are also contributing factors. Psychological interventions that address these issues are indicated. Statement of contribution What is already known on this subject? Research investigating psychological reactions and adjustment after limb loss has primarily focused on lower limb loss. Little research has investigated psychological adjustment or distress following upper extremity loss. Lower extremity limb loss is more likely to be from a disease process while upper extremity limb loss is more likely to be due to traumatic injuries. Upper extremity limb loss possesses a qualitatively different experience as upper limb amputation is more readily apparent to others, impacts activities of daily living, and limits instrumental function in social and non-verbal communication. What does this study add? A significant percentage of individuals with upper limb loss report significant levels of depression, PTSD, and mixed depression and PTSD. Moreover, women and minority clients were more likely to report clinically significant levels of depression and mixed PTSD and depression. Activity restriction and pain interference’s contributions in the final model helped to elucidate the clinical picture of psychological distress for persons with upper extremity limb loss. Greater activity restriction and limitations from pain interference increased the likelihood of reporting clinically significant levels of psychological distress.

Kearns, N. T., M. B. Powers, W. T. Jackson, T. R. Elliott and T. Ryan (2018). “Posttraumatic stress disorder symptom clusters and substance use among patients with upper limb amputations due to traumatic injury.” Disabil Rehabil Sep 5: 1-8. [Epub ahead of print].

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PURPOSE: Examining the relationship between posttraumatic stress disorder and posttraumatic stress disorder symptom clusters (re-experiencing, avoidance, hyperarousal, emotional numbing) on three substance use measures among individuals with upper limb amputation due to traumatic injury – an understudied population with high rates of posttraumatic stress disorder. METHODS: Multi-site, cross-sectional design. Participants (N = 236) were recruited from seven prosthetic rehabilitation centres across the USA and completed measures of PTSD, alcohol use, prescription medication overuse, and illicit drug use. RESULTS: Twenty-six percent of participants screened positive for posttraumatic stress disorder, 39% for problematic alcohol use, 12% for prescription medication overuse, and 7% for illicit drug use. No association was found between posttraumatic stress disorder or posttraumatic stress disorder symptoms clusters on problematic alcohol use. However, hyperarousal symptoms increased odds of overusing prescription medication (odds ratio = 3.30); further, a positive screen for posttraumatic stress disorder increased odds of illicit drug use (odds ratio = 2.95). CONCLUSIONS: These findings demonstrate the importance of assessing psychological well-being and a variety of substance use behaviours following amputation from traumatic injury. These findings may also provide clinically-relevant targets for prevention and intervention regarding prescription medication and illicit substance use, such as incorporating evidence-based treatment for posttraumatic stress disorder hyperarousal symptoms (e.g., prolonged exposure) and/or integrated treatment for posttraumatic stress-substance misuse (e.g., Seeking Safety) into patients’ long-term inpatient/outpatient rehabilitation plans. Implications for rehabilitation Posttraumatic stress disorder hyperarousal symptoms increased odds of overusing prescription medication among individuals with upper limb amputation due to traumatic injury; a positive screen for posttraumatic stress disorder increased odds of illicit drug use. Psychological assessments should be incorporated into treatment and rehabilitation plans following amputation from traumatic injury. Rehabilitation specialists should consider adding or integrating evidence-based treatment for posttraumatic stress disorder into patients’ long-term rehabilitation plan to reduce risk for problematic substance use. Findings support calls by the Centre for Disease Control and Prevention to overhaul prescription medication guidelines, including the need to assess risk and address harms concerning overuse of prescription medication.

Kearns, N. T., J. K. Peterson, L. Smurr Walters, W. T. Jackson, J. M. Miguelez and T. Ryan (2018). “Development and Psychometric Validation of Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL).” Arch Phys Med Rehabil 99(9): 1789-1797.

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OBJECTIVES: (1) To develop a performance-based measure for adult upper limb (UL) prosthetic functioning through broad (ie, overall performance) and functional domain-specific (eg, control skills) assessment of commonplace activities; (2) to conduct initial psychometric evaluation of the Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). DESIGN: Internal consistency of CAPPFUL and interrater reliability for task, functional domain, and full-scale (sub)scores among 3 independent raters were estimated. Known-group validity was examined comparing scores by amputation level. Convergent validity was assessed between CAPPFUL and 2 hand dexterity or function tests; discriminant validity was assessed against self-reported disability. SETTING: Six prosthetic rehabilitation centers across the United States. PARTICIPANTS: Subjects (N=60) with UL amputation using a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: Interrater reliability was excellent for scoring on the task, domain, and full-scale scores (intraclass correlation coefficients=.88-.99). Internal consistency was good (alpha=.79-.82). Generally, subjects with higher UL amputation levels scored lower (worse) than subjects with lower UL amputation levels. CAPPFUL demonstrated strong correlations with measures of hand dexterity or functioning (rs=-.58 to .72) and moderate correlation with self-reported disability (r=-.35). CONCLUSIONS: CAPPFUL was designed as a versatile, low-burden measure of prosthesis performance for any UL functional prosthetic device type and any UL amputation level. CAPPFUL assesses overall performance and 5 functional performance domains during completion of 11 tasks that require movement in all planes while manipulating everyday objects requiring multiple grasp patterns. Psychometric evaluation indicates good interrater reliability, internal consistency, known-group validity, and convergent and discriminant validity.

Kearns, N. T., J. K. Peterson, L. Smurr Walters, W. T. Jackson, J. M. Miguelez and T. Ryan (2018). “Development and Psychometric Validation of Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL).” Arch Phys Med Rehabil. May 16. [Epub ahead of print].

Full text of this article.

OBJECTIVES: (1) Develop a performance-based measure for adult upper limb (UL) prosthetic functioning through broad (i.e. overall performance) and functional domain-specific (e.g., control skills) assessment of commonplace activities; (2) conduct initial psychometric evaluation of the Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). DESIGN: Internal consistency of CAPPFUL and interrater reliability for task, functional domain, and full scale (sub)scores among three independent raters were estimated. Known-group validity was examined comparing scores by amputation level. Convergent validity was assessed between CAPPFUL and two hand dexterity/function tests; discriminant validity against self-reported disability. SETTING: Six prosthetic rehabilitation centers across the United States. PARTICIPANTS: Subjects (n = 60) with UL amputation utilizing a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Not applicable. RESULTS: Interrater reliability was excellent for scoring on the task, domain, and full scale scores (ICCs = .88-.99). Internal consistency was good (alpha = .79-.82). Generally, subjects with higher amputation levels scored lower (worse) than subjects with lower amputation levels. CAPPFUL demonstrated strong correlations with measures of hand dexterity/functioning (rs = -.58-.72); moderate correlation to self-reported disability (r = -.35). CONCLUSIONS: CAPPFUL was designed as a versatile, low burden measure of prosthesis performance for any UL functional prosthetic device type and any UL amputation level. CAPPFUL assesses overall performance, as well as five functional performance domains, during completion of 11 tasks that require movement in all planes while manipulating everyday objects requiring multiple grasp patterns. Psychometric evaluation indicates good interrater reliability, internal consistency, known-group validity, and convergent and discriminant validity.RE