Introduction: Complex regional pain syndrome (CRPS) is a form of neuropathic pain that sometimes develops after trauma or surgery. While diagnostic criteria have been debated, there is agreement participation in rehabilitation should be the primary management. However, there are gaps in the evidence guiding assessment and treatment choices for individuals with CRPS. The purpose of this thesis was to advance the rehabilitation of CRPS by 1) ongoing development and refinement of evaluations for the specific symptoms of CRPS, and 2) to investigate effectiveness of a new treatment (somatosensory rehabilitation) posited to address allodynia associated with CRPS. Methods: We conducted a series of 4 studies addressing various aspects of CRPS assessment and the somatosensory rehabilitation method: a) a cognitive debriefing study for content validation of the Patient-Reported Hamilton Inventory for CRPS; b) English translation and cultural validation of the Radboud Evaluation of Sensitivity; c) a retrospective cohort study of the effectiveness of somatosensory rehabilitation for allodynia in the upper limb; and d) a pilot study of the somatosensory rehabilitation method to consider the measurement properties of the embedded evaluation tools of allodynography and the rainbow pain scale, and to provide estimates for future controlled trials of effectiveness. Results: The cognitive debriefing study identified potentially problematic items, and constructs which needed enhancement in future versions of the PR-HICRPS assessment. The second paper reported the translation and cultural validation of the RES-E, finding support for test-retest reliability, internal consistency, and preliminary evidence for construct validity and reproducibility. The third paper presented preliminary evidence of a strong effect size for the SRM in an uncontrolled consecutive cohort. Finally, the fourth paper provides an interm analysis of the psychometric properties of allodynography and the rainbow pain scale, and estimates large sample sizes will be required for future trials. Discussion and Conclusion: None of the assessment tools described herein is ready for unrestricted use in clinical practice or research. Although the effect size estimates for somatosensory rehabilitation from the retrospective cohort are encouraging, the incomplete pilot data suggests large, multi-site trials and careful selection of the primary outcome measures will be required for future, rigorous trials of this method. / Dissertation / Doctor of Philosophy (PhD) / Complex regional pain syndrome (CRPS) is a painful collection of symptoms that can develop after trauma. Why it happens is not well understood, but most scientists and health care providers agree that rehabilitation should be the primary focus for managing the painful consequences of this condition. There is a need for simple and accurate ways to assess CRPS, as well as to treat it. Better assessment will support treatment that is more targeted to the symptoms of the individual. One of the very challenging symptoms experienced by persons with CRPS is painful sensitivity of the skin, also known as allodynia. This thesis describes the development and testing of several new patient-reported assessments for CRPS and allodynia, as well as two studies on a new method of treatment for allodynia.

Analyzing the political, legal, and cultural outcomes of the protests against the 2017 G20 Summit in Hamburg (the NoG20 protests), this thesis departs from the observation that violent protests may produce outcomes that seem counterintuitive at first sight. After the NoG20 protests, Hamburg’s government introduced a police identification statute that required officers to wear individually assigned codes during riot police operations. This was intended to make police more accountable to the public by allowing recognition of specific officers in cases of alleged misbehavior. This policy change seemed surprising, given that the heavy escalations of violence that characterized the protests were primarily attributed to the NoG20 activists, rather than to police. This thesis examines this seeming paradox from three different perspectives: first, from a policy-process perspective that reconstructs the decision in its temporal context; second, from a legal perspective that focuses on the interplay of political decision-making and judicial review of the occurrences; and third, from a discourse-oriented perspective that analyzes changes in the discursive opportunity structure associated with the NoG20 protests. The overall analysis indicates that protests may have multiple outcomes that a) may be interlinked, b) may both constrain and enable collective and legislative action, c) may be unintended by both collective and institutional actors, and d) should be analyzed in their historical context, as they may be the result of processes that began well before a given protest. This thesis finds that the decision to introduce a police identification statute was the outcome of a complex meaning-making process—a series of “struggles over credibility” between state authorities and NoG20 activists as well as their supporters that were played out in various arenas, including parliament, the media, and the courts. The findings suggest that rather than “triggering” change or adding entirely new topics to decision-makers’ agendas, the NoG20 protests functioned as a “focusing event,” a “catalyst” for change, intervening in ongoing, long-term processes. In terms of methodology, this thesis contributes to the literature by demonstrating that a processual approach that pays particular attention to temporal sequence and the dynamic interactions among collective actors and other actors can help to address one of the major challenges of outcome research—to establish a link between collective action and an observed outcome. On the conceptual level, the thesis contributes to the literature in several ways. First, it demonstrates that moving beyond the “success” or “failure” understanding that is particularly dominant in policy-related outcome research can help overcome some of the field’s shortcomings and broaden its analytical scope as it draws our attention to potentially new phenomena, including the unintended effects of collective action. Second, it benefits our understanding of the outcomes of both collective action—violent or not—and repression by viewing outcomes as “snapshots” (i.e., intermediate results of a process in which change is still underway). Finally, it potentially helps to resolve some of the inconsistencies inherent in particular research on the effects of repression by promoting understanding of the temporality inherent in state responses to collective action, whether they are legal or political.

No description available.

No description available.

No description available.

No description available.

Autism spectrum disorders (ASD) are associated with many different levels of language and social impairment, differences in levels of cognitive impairment, varying levels of aberrant behavior, and discrepancies in the presence or amount of restrictive and repetitive behavior. The heterogeneity found within the ASD population is coupled with significant heterogeneity in outcome for these individuals. Although interventions based on the principles of applied behavior analysis have been repeatedly cited as evidence-based for individuals with autism, significant discrepancies in outcome are evident within the literature. The heterogeneity in treatment outcome has been hypothesized as related to the heterogeneity of children included within the autism spectrum as well as differences related to treatment variables. The current study evaluated individual child characteristics and differences related to intervention intensity and fidelity as predictors of outcome after one year of exposure to a behaviorally based intervention. The primary goal of this study was to identify individual and treatment level characteristics that were predictive of differences in outcome for children with ASD. Information was gathered from a total of 368 students with autism spectrum disorders in kindergarten through second grade classrooms in the School District of Philadelphia. Correlational analyses and multiple regression analyses indicated that increased levels of expressive language skills at the start of the intervention year were correlated with and predictive of improved outcome. However, no other child level variables were related to differential outcomes. Additionally, higher levels of treatment intensity and treatment fidelity were associated with improved outcome. / School Psychology

Bipolar Disorder is frequently associated with a number of poor outcomes including, but not limited to, a significant impairment in the ability to return to premorbid levels of occupational and psychosocial functioning, often despite the remission of mood symptoms. An extensive line of research has pointed toward deficits in cognitive functioning as playing an important role in this persistent disability, with a number of studies demonstrating the presence of numerous cognitive impairments during the inter-episode period. Also present during affective episodes as well as the inter-episode periods are reports of pervasive sleep disturbance. Sleep disturbance has been associated with the onset of manic episodes and is an oft-reported prodrome of illness onset. Despite the presence of deficits in these two domains of functioning during affective episodes as well as the inter-episode phase, there has been no evaluation of the degree to which these systems may interact to maintain such high rates of functional disability. The current study attempted to integrate these three separate lines of research to examine the role sleep disruption plays in both cognitive and occupational functioning in individuals with bipolar disorder. Seventy-two males and females with bipolar disorder in the euthymic phase (n=24), primary insomnia (n=24) or no psychological or medical diagnoses (n=24) completed a week of prospective assessment of sleep disruption via self-report and actigraphy. At the culmination of the sleep assessment period, all participants were administered a battery of neuropsychological tests of executive functioning, working memory, verbal learning, and attention. Additionally, participants completed self-reports of mood symptoms and current and lifetime occupational functioning. Results were mixed relative to hypotheses. Data supports persistent sleep disturbance among individuals with bipolar disorder when assessed via self-report, but no significant differences were observed compared to controls when assessed via actigraphy. Bipolar participants exhibited significantly poorer performance on measures of verbal learning and working memory, but no other cognitive deficits were observed relative to insomnia and control participants. Bipolar participants had a greater lifetime history of being fired compared to insomnia or control participants, and deficits in executive inhibition and switching were associated with increased lifetime firings across the sample. Sleep disturbance, either subjective or objective, failed to mediate this association. Findings are partially consistent with previous reports of persistent sleep disturbance and cognitive impairment among individuals with BD in the euthymic phase. More research should be conducted to better understand the underpinnings of functional impairment in BD. / Psychology

OBJECTIVES: During health guideline development, panel members often have implicit, different definitions of health outcomes that can lead to variability in evidence synthesis and recommendations. McMaster GRADE Centre researchers developed a standardized description of health outcomes using the health marker state format. We aimed to determine which aspects of the development, content, and use of marker states were valuable to guideline developers. STUDY DESIGN & SETTING: We conducted a case study of marker state development with the European Commission Initiative on Breast Cancer (ECIBC) Guidelines Development Group (GDG). Eighteen GDG members provided written and interview feedback on the process. Using the health marker states, 2 health utility rating surveys were conducted near the beginning and end of development respectively. RESULTS: We developed 24 marker states for outcomes related to breast cancer screening and diagnosis. Feedback from GDG members revealed that marker states could be useful for developing recommendations and improving transparency of guideline methods. Comparison of the two health utility surveys showed a decrease in standard deviation in the second survey across 21 (88%) of the outcomes. CONCLUSIONS: Health marker states are a promising method, satisfying the pre-requisite of being feasible, acceptable, and with some initial result on reduction of variance of health utility scores. / Thesis / Master of Public Health (MPH) / OBJECTIVES: During health guideline development, panel members often have implicit, different definitions of health outcomes that can lead to variability in evidence synthesis and recommendations. McMaster GRADE Centre researchers developed a standardized description of health outcomes using the health marker state format. We aimed to determine which aspects of the development, content, and use of marker states were valuable to guideline developers. STUDY DESIGN & SETTING: We conducted a case study of marker state development with the European Commission Initiative on Breast Cancer (ECIBC) Guidelines Development Group (GDG). Eighteen GDG members provided written and interview feedback on the process. Using the health marker states, 2 health utility rating surveys were conducted near the beginning and end of development respectively. RESULTS: We developed 24 marker states for outcomes related to breast cancer screening and diagnosis. Feedback from GDG members revealed that marker states could be useful for developing recommendations and improving transparency of guideline methods. Comparison of the two health utility surveys showed a decrease in standard deviation in the second survey across 21 (88%) of the outcomes. CONCLUSIONS: Health marker states are a promising method, satisfying the pre-requisite of being feasible, acceptable, and with some initial result on reduction of variance of health utility scores.

Patient-reported outcome measures (PROMs) are becoming an integral part of healthcare decision making. Clinical trials, systematic reviews, and clinical practice guidelines incorporate them to learn about the effect of medical interventions in patients’ health status, without interference or mediation from clinicians or proxies. The use of these types of measures, however, is not without challenges. In particular, the complexity of the PROMs makes it difficult for patients, clinicians, and researchers to fully grasp the extent to which a treatment effect is negligible or trivial, small but important, moderate, or large. One of the most documented ways to address this issue is the use of the minimal important difference (MID), the smallest change in a PROM, either beneficial or harmful, that patients would perceive as important. A patient-oriented way to determine this threshold is the estimation of an anchor-based MID, where PROM results are compared against an external independent criterion the anchor that is in itself understandable and relevant for patients. This dissertation is an effort to facilitate the identification, evaluation, and utilization of MID estimates for PROMs. First, this thesis describes the development and reliability assessment of a new instrument to determine the credibility of primary studies ascertaining MID estimates, Second, it describes the conduct of a systematic survey to inform the creation of an inventory of all available anchor-based MIDs in the medical literature until 2015. Third, it reports an analysis of the state of the art of current MID estimates from a reporting and credibility perspective. Finally, this work concludes with a summary of the main results, presentation of strengths and limitations, and insights related to the implications for future research. / Dissertation / Doctor of Philosophy (PhD)