Principles and Practice of Sleep Medicine

Background
This is an update of the Cochrane review 'Neuropsychological rehabilitation for multiple sclerosis' (first published in The Cochrane Library 2011, Issue 11).

Cognitive deficits are a common manifestation of multiple sclerosis (MS) and have a significant effect on the patient's quality of life. Alleviation of the harmful effects caused by these deficits should be a major goal of MS research and practice. 

Objectives
To assess the effects of neuropsychological/cognitive rehabilitation on health-related factors, such as cognitive performance and emotional well-being in patients with MS.

Search methods
The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Trials Search Co-ordinator searched their Specialised Register which, among other sources, contains trials from CENTRAL (The Cochrane Library 2013, Issue 2), MEDLINE, EMBASE, CINAHL, LILACS, PEDro and clinical trials registries (28 May 2013). We contacted authors of the studies for additional information.

Selection criteria
Randomised controlled trials (RCTs) and quasi-randomised trials evaluating the effects of neuropsychological rehabilitation in MS compared to other interventions or no intervention.

Data collection and analysis
Two review authors individually judged the eligibility of the included studies, assessed risk of bias and extracted data. We combined results quantitatively in meta-analyses according to the intervention type: 1) cognitive training and 2) cognitive training combined with other neuropsychological rehabilitation methods.

Main results
Twenty studies (986 participants; 966 MS participants and 20 healthy controls) fulfilled the inclusion criteria. The mean age of the participants was 44.6 years, mean length of education was 12.3 years and 70% of the participants were women. Most of the participants had a relapsing-remitting course of disease. The mean Expanded Disability Status Scale score was 3.2 and the mean duration of disease was 14.0 years.

On the basis of these studies, we found low-level evidence that neuropsychological rehabilitation reduces cognitive symptoms in MS. Cognitive training was found to improve memory span (standardised mean difference (SMD) 0.54, 95% confidence interval (CI) 0.20 to 0.88, P = 0.002) and working memory (SMD 0.33, 95% CI 0.09 to 0.57, P = 0.006). Cognitive training combined with other neuropsychological rehabilitation methods was found to improve attention (SMD 0.15, 95% CI 0.01 to 0.28, P = 0.03), immediate verbal memory (SMD 0.31, 95% CI 0.08 to 0.54, P = 0.008) and delayed memory (SMD 0.22, 95% CI 0.02 to 0.42, P = 0.03). There was no evidence of an effect of neuropsychological rehabilitation on emotional functions.

The overall quality, as well as the comparability of the included studies, was relatively low due to methodological limitations and heterogeneity of interventions and outcome measures. Although most of the pooled results in the meta-analyses yielded no significant findings, 18 of the 20 studies showed some evidence of positive effects when the studies were individually analysed.

Authors' conclusions
This review found low-level evidence for positive effects of neuropsychological rehabilitation in MS. The interventions and outcome measures included in the review were heterogeneous, which limited the comparability of the studies. New trials may therefore change the strength and direction of the evidence.

Neuropsychological rehabilitation for multiple sclerosis.

Cognitive impairment affects more than half of all individuals living with multiple sclerosis (MS). We hypothesized that training at home with an adaptive online cognitive training program would have greater cognitive benefit than ordinary computer games in cognitively-impaired adults with MS. This was a double-blind, randomized, active-placebo-controlled trial. Participants with MS were recruited through Stony Brook Medicine and randomly assigned to either the adaptive cognitive remediation (ACR) program or active control of ordinary computer games for 60 hours over 12 weeks. Training was remotely-supervised and delivered through a study-provided laptop computer. A computer generated, blocked stratification table prepared by statistician provided the randomization schedule and condition was assigned by a study technician. The primary outcome, administered by study psychometrician, was measured by change in a neuropsychological composite measure from baseline to study end. An intent-to-treat analysis was employed and missing primary outcome values were imputed via Markov Chain Monte Carlo method. Participants in the ACR (n = 74) vs. active control (n = 61) training program had significantly greater improvement in the primary outcome of cognitive functioning (mean change in composite z score±SD: 0·25±0·45 vs. 0·09±0·37, p = 0·03, estimated difference = 0·16 with 95% CI: 0·02–0·30), despite greater training time in the active control condition (mean±SD:56·9 ± 34·6 vs. 37·7 ±23 ·8 hours played, p = 0·006). This study provides Class I evidence that adaptive, computer-based cognitive remediation accessed from home can improve cognitive functioning in MS. This telerehabilitation approach allowed for rapid recruitment and high compliance, and can be readily applied to other neurological conditions associated with cognitive dysfunction.

Trial Registration: Clinicaltrials.gov NCT02141386

/pdf/cognitive-function-in-multiple-sclerosis-improves-with-4wrn7lhzp6.pdf

Cognitive function in multiple sclerosis improves with telerehabilitation: Results from a randomized controlled trial

OBJECTIVE: Cancer has long inspired fear but the effect of fear is not well understood; it seems both to facilitate and deter early diagnosis behaviours. To elucidate fear's behavioural effects, we systematically reviewed and synthesised qualitative literature to explore what people fear about cancer. METHODS: We searched Medline, Embase, PsycInfo, Web of Science, AnthroSource, and Anthrobase for studies on cancer fear in breast, cervical, and colorectal cancer screening, and analysed 102 studies from 26 countries using thematic synthesis. RESULTS: Fears of cancer emanated from a core view of cancer as a vicious, unpredictable, and indestructible enemy, evoking fears about its proximity, the (lack of) strategies to keep it at bay, the personal and social implications of succumbing, and fear of dying from cancer. CONCLUSIONS: This view of cancer as "an enemy" reprises the media's "war on cancer" theme, and may affect the acceptance of cancer early detection and prevention messages, since cancer's characteristics influenced whether "fight" or "flight" was considered appropriate. This article is protected by copyright. All rights reserved.

/pdf/what-do-people-fear-about-cancer-a-systematic-review-and-193xmhga6b.pdf

What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population.

Background: This is an update of the Cochrane review ‘Memory rehabilitation for people with multiple sclerosis’ (first published in the Cochrane Library 14 March 2012, Issue 3). Impairments in cognitive function, particularly memory, are common in people with multiple sclerosis (MS) and can potentially affect their ability to complete functional activities. There is evidence from single-case or small group studies that memory rehabilitation can be beneficial for people with MS, but findings from randomised controlled trials (RCTs) and systematic reviews have been inconclusive.
Objectives: To determine whether people with MS who received memory rehabilitation showed: 1. better outcomes in their memory functions compared to those given no treatment or receiving a placebo control; and 2. better functional abilities, in terms of activities of daily living, mood, and quality of life, than those who received no treatment or a placebo.
Search methods: We searched the Trials Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the CNS Group (2 June 2015) and the following electronic databases: The NIHR Clinical Research Network Portfolio database (NIHR CRN) (from 2010 to June 2015), The Allied and Complementary Medicine Database (AMED) (2010 to June 2015), British Nursing Index (BNI) (2010 to June 2015), PsycINFO (2011 to June 2015), and CAB Abstracts (2010 to June 2015). Start dates for the electronic databases coincided with the last search for the previous review. We handsearched relevant journals and reference lists.
Selection criteria: We selected RCTs or quasi-randomised trials ofmemory rehabilitation or cognitive rehabilitation for people with MS in which a memory rehabilitation treatment group was compared to a control group. Selection was conducted independently first and then confirmed through group discussion. We excluded studies that included participants whose memory deficits were the result of conditions other than MS unless we could identify a subgroup of participants with MS with separate results.
Data collection and analysis: Three review authors were involved in this update in terms of study selection, quality assessment, and data extraction. We contacted investigators of primary studies for further information where required. We conducted data analysis and synthesis in accordance with the Cochrane Handbook for Systematic Reviews ofInterventions (Higgins 2011). We performed a ’best evidence’ synthesis based on the methodological quality of the primary studies included.
Main results: We added seven studies during this update, bringing the total to 15 studies, involving 989 participants. The interventions involved various memory retraining techniques, such as computerised programmes and training on internal and external memory aids. Control groups varied in format from assessment-only groups, discussion and games, non-specific cognitive retraining, and attention or visuospatial training. The risk of bias of the included studies was generally low, but we found eight studies to have high risk of bias related to certain aspects of their methodology. We found significant effect of intervention on objective assessments of memory in both the immediate and long-term follow-ups: standardised mean difference (SMD) 0.23 (95% confidence interval (CI) 0.05 to 0.41) and SMD 0.26 (95% CI 0.03 to 0.49), respectively. We also found significant effect of intervention for quality of life in the immediate follow-up (SMD 0.23 (95% CI 0.05 to 0.41)). These findings showed that the intervention group performed significantly better than the control group. We also found a significant difference for activities of daily living (ADL) in the long-term follow-up (SMD -0.33 (95% CI -0.63 to -0.03)), showing that the control groups had significantly less difficulty completing ADLs than the intervention groups. We found no significant effects, either immediate or long-term, on subjective reports of memory problems (SMD 0.04 (95% CI -0.19 to 0.27) and SMD 0.04 (95% CI -0.19 to 0.27)); on mood (SMD 0.02 (95% CI -0.16 to 0.20) and SMD -0.01 (95% CI -0.21 to 0.20)); and on immediate follow-up for ADL (SMD -0.13 (95% CI -0.60 to 0.33)) and in the long term for quality of life (SMD 0.16 (95% CI -0.03 to 0.36)). We could not complete a sensitivity analysis of intention-to-treat in comparison with per-protocol analysis, due to insufficient information from the included papers. However, a sensitivity analysis of high- versus low-risk studies suggested that while quality of the trials did not affect most outcomes, differences were seen in the objective memory outcomes (both at immediate and long term) and quality of life (immediate) outcome, with studies with higher risk of bias inflating the overall effect size estimates for these outcomes, and the test of overall effect changing from being statistically significant to not significant when studies at high risk of bias were excluded. This suggests that lower-quality studies may have positively influenced the outcomes.
Authors’ conclusions: There is some evidence to support the effectiveness of memory rehabilitation on memory function, as well as on quality of life. However, the evidence is limited and does not extend to subjective reports of memory functioning or mood. Furthermore, the objective measures used are not ecologically valid measures, and thus potentially limit generalisability of these findings into daily life. Further robust RCTs of high methodological quality and better quality of reporting, using ecologically valid outcome assessments, are still needed.

/pdf/memory-rehabilitation-for-people-with-multiple-sclerosis-lxsc918ei0.pdf

Memory rehabilitation for people with multiple sclerosis

Purpose: To explore differences in demographic and illness-related variables among women with fibromyalgia syndrome (FMS) with documented sleep problems and those without.

Data sources: As part of the baseline assessments for a larger intervention study, 104 women with FMS wore an actigraph and completed a sleep log for 72 hours. Participants also completed a baseline questionnaire and a physical exam to quantify the Tender Point Index.

Conclusions: Although almost half (44%) of the women rated their sleep as bad or fairly bad, only 22 of the 104 women (21%) had objective sleep deficits (less than 6 hours sleep duration). The women with objective sleep deficits had significantly higher pain scores on the tender point index, perceived their sleep as significantly worse, and reported significantly more depressive symptoms and more negative impact of FMS on functioning than those without deficits. Descriptive statements in the sleep logs revealed frequent problems with energy, fatigue, and functioning for women in the sleep deficits group.

Implications for practice: Sleep problems are a major concern among women with FMS. Those with concurrent depressive symptoms, high pain, and limited functioning may be candidates for in-depth sleep assessment and behavioral programs to improve sleep.

/pdf/subjective-and-objective-sleep-difficulties-in-women-with-50hrj3ipt9.pdf

Subjective and objective sleep difficulties in women with fibromyalgia syndrome.

There is evidence that early detection from breast cancer screening is an effective means to reduce overall mortality from breast cancer. Findings from multiple research studies suggest that women with chronic disabling conditions are less likely to participate in breast cancer screening due to the multiple barriers they face. Barriers include those related to finances, environment, physical limitations, health carers' attitudes and lack of knowledge, and psychosocial issues. The purpose of this article is to provide an overview of the existing evidence of the barriers to breast cancer screening experienced by women with physical disabilities. Rehabilitation nurses that work with women who have chronic disabling conditions can be instrumental in eliminating these barriers to breast cancer screening through their efforts to promote health which is consistent with the philosophy of maximizing the health potential and quality of life of these women whose needs are often overlooked.

Breast Cancer Screening Barriers and Disability

Recent literature indicates that women with various types of chronic disabling conditions are less likely to participate in routine breast cancer screening than those without disabling conditions. The purpose of this study was to identify barriers and facilitators related to breast cancer screening among women with multiple sclerosis (MS). A total of 36 women with MS, whose mean age was 55 years, participated in a semistructured interview in a private setting. The interviews were audiotaped and transcribed verbatim. The interview questions, informed by the Health Belief Model, addressed knowledge, experience, barriers, and facilitators related to breast cancer screening. Qualitative descriptive techniques were used to analyze the data. About 94% of the women in the sample were white, 67% were married, 47% had at least a bachelor's degree, and 31% were unemployed because of their disability. The results showed that 70% of these women had received annual mammograms and 50% had performed monthly breast self-...

Barriers and Facilitators to Breast Cancer Screening: A Qualitative Study of Women with Multiple Sclerosis.

Background Poverty is linked to poorer health outcomes across the life span. Nurses must understand how poverty impacts health and the ability to achieve social mobility. This article describes a poverty simulation exercise, In Their Shoes. Method Scenarios of clients in need of community resources were developed. Using public transportation, students travelled to agencies to collect information about accessing resources. Students were introduced to content about poverty, income inequality, social mobility, and critical social theory prior to the simulation exercise. After the simulation, students returned to the classroom and reflected on the experience. Results In Their Shoes received positive feedback. Students expressed surprise at the number of community resources, frustration by the challenges encountered, and dedication to being aware and compassionate advocates for underserved clients. Conclusion Nursing programs should develop and evaluate similar activities to expose students to the challenges of living in poverty, and how this affects health and nursing practice.

"If Only We Could Have Them Walk a Mile in Their Shoes": A Community-Based Poverty Simulation Exercise for Baccalaureate Nursing Students.

Background Historically, nursing curricula have not offered opportunities for students to develop hands-on political competence. A public health policy simulation can improve students' ability to be change agents for health policy through advocacy. Method The public health policy simulation was a combination of didactic preparation and hands-on application of advocacy training. At the simulation, held at the State Capitol, students visited legislators, gave an oral testimony before a mock hearing committee, and received feedback from legislators. Results In general, students expressed being more knowledgeable and confident about the legislative process, advocacy for public health issues, communication with legislators, and the role of nursing in the public health policy arena. Students reported increased likelihood of advocacy for public health issues. Conclusion Public health policy simulation should be part of nursing curricula to help to create a culture that dictates that public health policy is an integral component of the nursing profession. [J Nurs Educ. 2019;58(3):178-181.].

Public Health Policy Simulation

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