While a substantial number of studies exist in the medical and mental health fields reflecting the physical and psychological implications for couples with chronic back pain, studies thus far have focused on the independent perceptions of each partner. Research investigating how couples jointly perceive the impact of chronic back pain on their relationship is absent. This qualitative study explored eight couples' joint perceptions of how chronic back pain has impacted their relationship. Using thematic analysis, dominant themes to emerge included (1) relationship changes, (2) influential relationship factors, and (3) making sense of pain. Limitations of the study as well as future research and clinical implications are also discussed. / Master of Science

Recent studies have shown the efficacy and practicality of the integration of complementary and alternative therapies and biomedical treatments for various diseases and illnesses, including high blood pressure, diabetes, epilepsy, and cancer. Saper et al. (2013) demonstrated that once-weekly yoga classes were equally as effective for relieving chronic low back pain in low-income, minority populations than twice-weekly yoga classes. Pain medication data collected from this 12-week study was used to examine the effect of yoga on analgesic use. Pain medications were categorized into four major groups: (1) acetaminophen, (2) opiates, (3) non-steroidal anti-inflammatory drugs (NSAIDS), and (4) other. The average number of NSAID pills taken daily decreased from baseline to 12 weeks. In addition, there was no statistically significant difference in the average number of any type of analgesic taken between once- and twice-weekly yoga groups from baseline to 12 weeks. Our findings suggest that yoga is most useful for individuals with mild to moderate chronic low back pain; however, further studies with more powerful sample sizes must be conducted in order to make more precise conclusions.

The tick-borne Lyme disease, caused by the bacterium Borrelia burgdorferi, as well as some other Borrelia species, is the subject of a dispute as to whether its conditions persist following recommended antibiotic treatment lasting no more than three weeks. Advocates for the existence of chronic Lyme disease point to numerous animal models that show some traces of the bacteria remaining after treatment and call for both the long term use of antibiotics and for the disease to be recognized as chronic and to be diagnosed more expediently. Opponents of the existence of chronic Lyme disease argue that the scientific evidence for these arguments is insufficient, citing that long term symptoms are actually signs of other diseases erroneously grouped with Lyme, that current antibiotic regimens suffice for Lyme disease treatment, and that additional antibiotics beyond current treatments provide no increase in beneficial outcomes. The evidence currently is insufficient to support many of the claims by supporters of chronic Lyme disease and further studies must be done before evidence from the animal models can be applied to human patients. The fact that Borrelia burgdorferi in particular, and perhaps other members of the Borrelia genus, has evolved many singularly peculiar traits such as a lack of reliance on iron and a large extrachromosomal genome suggest that it is not outside the realm of possibility that there is some other facet of Lyme disease not currently recognized or understood. Future exploration is needed to fully understand mechanisms of pathogenesis of this bacterium in order to either confirm or deny the ability of Lyme disease to persist in humans following treatment.

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Introduction: Prevalence of chronic conditions continues to rise in North America. Despite the lack of evidence supporting their use, patient contracts are commonly used by medical professionals to manage such conditions. To date, literature reviews on patient contracts has been limited to randomized controlled trials, with specific purposes and limited populations. The purpose of this study is to describe ‘for what’ and ‘how’ medical contracts are being used for the management of chronic medical conditions. Methods: In order to capture and describe the breadth of knowledge around medical contracts in the literature, a scoping review was conducted. This inclusive approach allowed for analytic reinterpretation of research activity, gaps in the literature to be identified and further avenues of inquiry to be opened. Database searches included Medline, EMBASE, AMED, PsycINFO, Cochrane, CINAHL and Nursing & Allied Health. Results: A total of 7,528 articles resulted from the original search. Seventy-six articles were included in the final review. Multiple types of studies were represented with limited follow-up durations. Extensive variety was seen for contract target population, clinical setting and co-interventions. Purposes for initiating contracts included: 1) behavior change and skill development, including goal development and problem solving; 2) altering beliefs and knowledge, including motivation and perceived self-efficacy; 3) improving interpersonal relationships and role clarification; 4) improving the quality and process of chronic care; and 5) altering objective and subjective health indices. In relationship to how contracts are used, their development, application of behavioral theory, inclusion of patient input, training for their use and implementation processes were inconsistently described. Conclusion: More research is required to determine if contracts are capable of accomplishing their intended purposes. Questions remain regarding their rationale, development and implementation. / Thesis / Master of Public Health (MPH) / Rates of chronic medical conditions continue to rise in North America. To manage such conditions, medical professionals commonly use patient contracts, defined as any type of agreement by which one or both parties agree to a set of behaviors related to the care of the patient. The purpose of this study is to describe ‘for what’ and ‘how’ medical contracts are being used for the management of chronic medical conditions. A scoping literature review was undertaken. Extensive variety was seen in the literature for contract target population, clinical setting and co-interventions. Purposes for initiating contracts included: 1) behavior change and skill development; 2) altering beliefs and knowledge; 3) improving interpersonal relationships; 4) improving the quality and process of care; and 5) altering objective and subjective health indices. Contract development and implementation processes were inconsistently described. More research is required to determine if contracts are capable of accomplishing their intended purposes. Questions remain regarding their rationale, development and implementation processes.

Background: International guidelines provide recommendations for early chronic kidney disease care. This thesis was completed to 1) measure the quality of chronic kidney disease care and identify gaps, 2) identify reasons why patients do not receive recommended care, and 3) determine if these guideline-recommended practices are associated with better patient outcomes. Methods: Population-based cohort studies were conducted for studies 1, 3 and 4. Using consensus-based indicators, study 1 quantified the quality of care for patients with early chronic kidney disease. Study 2 was a qualitative descriptive study eliciting primary care physicians’ perceived enablers and barriers to follow-up laboratory testing to confirm chronic kidney disease. Study 3 assessed the association between non-steroidal anti-inflammatory drug (NSAID) use versus non-use and adverse clinical outcomes among older adults. Study 4 assessed whether routine serum creatinine and potassium monitoring (versus no monitoring) following angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) initiation among older adults associated with better outcomes. Results: In study 1, most recommendations were being followed; however, some care gaps were identified. For example, half of the patients with initial abnormal kidney test results did not receive follow-up tests. This finding prompted study 2, where enablers and barriers to this practice were identified. Providers were aware that they should be ordering follow-up tests and had the resources to do so. However, some providers perceived this practice as low priority. In study 3, NSAID use was associated with a higher risk of complications. In study 4, routine ACEi / ARB monitoring did not prevent adverse outcomes. Conclusions: This thesis provides a better understanding of care gaps for patients with early chronic kidney disease in Ontario, and reasons for one of these care gaps. This research also provides evidence to help strengthen guideline recommendations (NSAID avoidance) or refute them (ACEi / ARB monitoring). / Thesis / Doctor of Philosophy (PhD) / Chronic kidney disease is a medical condition where a person’s kidney function is permanently reduced. Family doctors are responsible for the care of patients with early chronic kidney disease. However, many patients may not be receiving the right treatments from their family doctors to keep their kidneys healthy. This research used Ontario healthcare data to identify care gaps for patients with early chronic kidney disease. Interviews were then done with family doctors to identify reasons for one of these care gaps; specifically, why doctors do not always repeat blood and urine tests to confirm if patients have chronic kidney disease. Finally, this research looked at whether providing certain treatments led to better patient outcomes. This information can be used to update current guidelines and to inform strategies which help patients with chronic kidney disease receive the best possible care.

Indiana University-Purdue University Indianapolis (IUPUI) / Older adults with persistent pain experience reduced physical functioning, increased disability, and higher rates of depression. Previous research suggests that different types of positive and negative expectancies (e.g., optimism and hopelessness) may be associated with the severity of these pain-related outcomes. Moreover, different types of expectancies may interact with perceived control to predict these outcomes. However, it is unclear whether different types of expectancies are uniquely predictive of changes in pain-related outcomes over time in older adults and whether perceived control moderates these relationships. The primary aims of the current study were to 1) examine how the shared and unique aspects of optimism and hopelessness differentially predict changes in pain-related outcomes (i.e., pain severity, pain interference, disability, and depressive symptoms) in older adults experiencing persistent pain over a 10-year and 2-year timeframe and 2) examine whether perceptions of control over one’s health moderate these relationships. The present study sampled older adults with persistent pain who participated in a nationally representative, longitudinal study (i.e., The Health and Retirement Study) at three timepoints across a 10-year period. First, confirmatory factor analyses (CFA) were conducted to determine appropriate modeling of expectancy variables. Second, mixed latent and measured variable path analyses were created to examine the unique relationships between expectancy variables and changes in pain-related outcomes over both a 10- year and 2-year period. Finally, mixed latent and measured variable path analyses and PROCESS were used to test perceived control as moderator of the relationships between expectancy variables and changes in pain-related outcomes over time. CFA results suggested that measures of optimism and hopelessness were best understood in terms of their valence, as positive (i.e., optimism) or negative (i.e., pessimism and hopelessness) expectations. Results from path analyses suggested that only negative, not positive, expectancies were significantly associated with worsening pain severity, pain interference, disability, and depressive symptoms across both 10-year and 2-year periods. Moderation analyses demonstrated inconsistent results and difficulties with replication. However, post-hoc path analyses found that perceptions of control over one’s health independently predicted some changes in pain-related outcomes over time, even when controlling for expectancies. Altogether, the current findings expand our knowledge of the associations between expectancies and pain by suggesting that negative expectancies are predictive of changes in mental and physical pain-related outcomes across years of time. The current study also suggests that positive and negative expectancies may be related, but distinct factors in older adults with persistent pain and that health-related perceived control may be predictive of changes in pain over time. The current discussion reviews these extensions of our current knowledge in greater detail, discusses the potential mechanisms driving these relationships through a theoretical lens, and identifies the implications of this work.