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Psychological interventions may make a valuable contribution to recovery following a mild traumatic brain injury (mTBI) and have been advocated for in treatment consensus guidelines. Acceptance and Commitment Therapy (ACT) is a more recently developed therapeutic option that may offer an effective approach. Consequently, we developed ACTion mTBI, a 5-session ACT-informed intervention protocol. To establish the feasibility of this intervention, we wanted to understand participants’ experiences of ACTion mTBI, determine acceptability and identify any refinements needed to inform a full-scale effectiveness trial. We recruited adults (≥16 years of age) diagnosed with mTBI who were engaged in community-based multidisciplinary rehabilitation. After completing the ACTion mTBI sessions, 23/27 (85.2%) participants (mean time post-injury: 28.0 weeks) completed a semi-structured interview about their experience of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed using a qualitative description approach. There were two overarching themes 1) attacking the concussion from a different direction and 2) positive impact on recovery which depicted participants’ overall experiences of the intervention. Within these overarching themes, our analysis also identified two subthemes: 1) helpful aspects of the intervention which included education and ACT processes (i.e., being present and being able to step back) and 2) “ contextual factors that enabled intervention effectiveness ” which included being equipped with tools, cultural and spiritual responsiveness, the therapeutic connection, and the intervention having a structured yet flexible approach to order of delivery to meet individual needs. Participants’ experiences support acceptability, cultural and spiritual responsibility of ACTion mTBI. Suggested refinements included enabling access to intervention over time, not just at one point during recovery and the addition of a brief check-in follow-up.

Fear avoidance behavior is related to symptom persistence and disability in various health conditions, such as chronic pain. Fear avoidance behavior also may impact recovery from mild traumatic brain injury (mTBI), but no measure of this construct has been psychometrically validated for the mTBI population. Adults who sustained an mTBI (n = 159) were recruited from three outpatient mTBI clinics. Participants completed the new Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI). The FAB-TBI includes 16 items drawn from well-established fear avoidance scales, primarily in the chronic pain literature. An exploratory factor analysis and Rasch analysis were conducted to evaluate the factor structure, dimensionality, and differential item functioning of the FAB-TBI. The FAB-TBI scale was found to have strong internal consistency (Cronbach's α = 0.9). Exploratory factor analysis suggested at least two distinct factors (activity avoidance and cogniphobia). Initial fit to the Rasch model was adequate, with one misfitting item. The model was not improved after removing the misfitting item. Best fit to the unidimensional Rasch model was achieved after items were combined into three super items based on exploratory factor analysis and retaining the misfitting item χ2(6, n = 159) = 2.1, p = 0.06). The FAB-TBI appears to be a psychometrically sound measure of fear avoidance behavior after mTBI. Conversion tables are made available to convert scores into interval-level data for future research.

Psychological interventions may make a valuable contribution to recovery following a mild traumatic brain injury (mTBI) and have been advocated for in treatment consensus guidelines. Acceptance and Commitment Therapy (ACT) is a more recently developed therapeutic option that may offer an effective approach. Consequently, we developed ACTion mTBI, a 5-session ACT-informed intervention protocol. To establish the feasibility of this intervention, we wanted to understand participants' experiences of ACTion mTBI, determine acceptability and identify any refinements needed to inform a full-scale effectiveness trial. We recruited adults ([greater than or equal to]16 years of age) diagnosed with mTBI who were engaged in community-based multidisciplinary rehabilitation. After completing the ACTion mTBI sessions, 23/27 (85.2%) participants (mean time post-injury: 28.0 weeks) completed a semi-structured interview about their experience of the intervention. Interviews were audio-recorded, transcribed verbatim and analysed using a qualitative description approach. There were two overarching themes 1) attacking the concussion from a different direction and 2) positive impact on recovery which depicted participants' overall experiences of the intervention. Within these overarching themes, our analysis also identified two subthemes: 1) helpful aspects of the intervention which included education and ACT processes (i.e., being present and being able to step back) and 2) \"contextual factors that enabled intervention effectiveness\" which included being equipped with tools, cultural and spiritual responsiveness, the therapeutic connection, and the intervention having a structured yet flexible approach to order of delivery to meet individual needs. Participants' experiences support acceptability, cultural and spiritual responsibility of ACTion mTBI. Suggested refinements included enabling access to intervention over time, not just at one point during recovery and the addition of a brief check-in follow-up.

Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS. Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives. Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.

ObjectiveTo investigate the prognostic value of the Subgroups for Targeted Treatment (STarT) Screening Tool adapted for concussion (STarT-C) on persistent symptoms and disability at 6–9 months following mild traumatic brain injury (mTBI).DesignSecondary analysis of two prospective studies: an observational cohort study in New Zealand and usual care control arm of a clinical trial in Canada (ClinicalTrials.gov Registry (NCT04704037)).SettingParticipants in the New Zealand cohort were recruited from concussion clinics (five sites) and those in the Canadian cohort were recruited from emergency departments/urgent care centres (eight sites).ParticipantsNew Zealand participants (n=93, median age 37 years, 60% women) were assessed at median=6 weeks post-injury (T1) and 6 months later (T2). Canadian participants (n=223, median age 38 years, 56% women) were assessed at median=2 weeks (T1) and 6 months later (T2).Main outcome measuresSymptoms at T2 were assessed using the validated Rivermead Postconcussion Symptoms Questionnaire (RPQ) and disability using the WHO Disability Assessment Schedule 2.0 12-item Interview.ResultsIn linear regression analyses, the STarT-C predicted symptom burden (R2=18–36%) and disability (R2=15–18%) at T2 in both cohorts. While the additional prognostic value over and above baseline variables was substantial (delta R2 8–40%), the additional prognostic value over the RPQ at T1 was variable and generally lower (delta R2=1–9%).ConclusionThe STarT-C—a brief screening tool—predicted persistent symptoms and disability in adults following mTBI. The incremental prognostic value of the STarT-C over the RPQ may be variable, but regardless, the tool may be useful for identifying those at risk of prolonged recovery who may benefit from early psychological intervention.

AbstractStudy designThis is a population-based prospective cohort study.ObjectivesTraumatic brain injury (TBI) is common among people with traumatic spinal cord injury (TSCI), but rates vary across studies associated with variable approaches to diagnosis. We aimed to determine if a published diagnostic algorithm could be consistently applied to capture co-occurring TBI among persons sustaining TSCI.SettingOne of two spinal centres in New Zealand (NZ), the Burwood Spinal Unit (BSU) captures approximately 45% of NZ TSCI admissions.MethodsAdults (age 16+) with TSCI admitted to the BSU between 1 January 2021 and 31 August 2021 (n = 51) were included. Clinical notes were audited prospectively to identify co-occurring TBI.ResultsWe identified co-occurring TBI in 39% of TSCI cases with a small number of additional suspected TBI cases where TBI could not be confidently ruled in or out. Including all TBI cases, suspected or otherwise resulted in up to 55% of the sample having sustained co-occurring TBI. There were difficulties applying the published algorithm, associated with inconsistent documentation of TBI indicators from acute to rehabilitation contexts.ConclusionsIn this study, the feasibility of a TBI diagnostic algorithm for the TSCI population was low. Alternative approaches to screening for TBI among people sustaining TSCI are needed. Greater consistency in documenting TBI across the continuum of care will ensure TBI if present, is included in treatment planning.

Objectives: To investigate variables associated with improvement in quality of life (QOL) after primary knee replacement. QOL outcomes between individuals undergoing total knee replacement (TKR) and unicompartmental knee replacement (UKR) were compared. Materials and Methods: Participants were adults ( n = 497) undergoing TKR or UKR for osteoarthritis between January 2017 and October 2020 in a large publicly funded tertiary hospital in New Zealand. Participants completed patient‐reported outcome measures of QOL, pain and function, preoperatively, 6 and 12 months postoperatively. Results: QOL improved pre‐ to postoperatively for both TKR and UKR groups, and the main QOL gains for both groups were evident in the first 6 months after joint replacement. Notably, QOL did not differ between groups at any assessment point ( p > 0.05). Improvement in QOL was more correlated with improved pain and function than with person factors such as demographics and comorbidity burden ( p < 0.01). Conclusions: This study adds to a growing literature showing that knee replacement contributes to substantial improvements in QOL outcomes. Future QOL outcome research in the knee replacement population should consider using more precise measures of function to better understand the impacts of these factors on QOL improvement.

Introduction: Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS. Methods: Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. Results: Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives. Conclusions: Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS. Keywords: Complex Regional Pain Syndrome; upper limb; healthcare experience; hand therapy; rehabilitation.

The purpose of this study is to examine the reliability, factor structure, and validity of the World Health Organization Disability Assessment Schedule (WHODAS 2.0 12 item version) in a sample of patients who were slow to recover from a mild traumatic brain injury (mTBI). Participants were 79 adults with mTBI recruited from one of four specialty outpatient clinics in Vancouver, Canada. The WHODAS 2.0 12 item version is a disease-nonspecific measure of disability representing six International Classification of Disability, Functioning, and Health activity and participation domains including cognition, mobility, self-care, interpersonal functioning, life activities, and participation. Results of analyses showed that the WHODAS 2.0 had high internal consistency and adequate construct and concurrent validity. A three factor structure emerged in this sample. The scale differentiated between patients with good and those with poor outcomes based on post-concussion syndrome, psychiatric, and pain status. Participants with multiple comorbidities reported the most disability on the WHODAS. Concurrent validity was also supported by lower WHODAS scores in participants who had returned to work versus those who had not. To our knowledge, this is the first study to evaluate the psychometric properties of the WHODAS 2.0 in a sample of people with mTBI. In summary, the WHODAS was sensitive to post-concussion syndrome after mTBI, as well as to health conditions that commonly co-occur with mTBI (e.g., mental health problems and chronic pain).

IntroductionPersistent symptoms after mild traumatic brain injury (mTBI) negatively affect daily functioning and quality of life. Fear avoidance behaviour, a coping style in which people avoid or escape from activities or situations that they expect will exacerbate their symptoms, maybe a particularly potent and modifiable risk factor for chronic disability after mTBI. This study will evaluate the efficacy of graded exposure therapy (GET) for reducing persistent symptoms following mTBI, with two primary aims: (1) To determine whether GET is more effective than usual care; (2) to identify for whom GET is the most effective treatment option, by evaluating whether baseline fear avoidance moderates differences between GET and an active comparator (prescribed aerobic exercise). Our findings will guide evidence-based care after mTBI and enable better matching of mTBI patients to treatments.Methods and analysisWe will conduct a multisite randomised controlled trial with three arms. Participants (n=220) will be recruited from concussion clinics and emergency departments in three Canadian provinces and randomly assigned (1:2:2 ratio) to receive enhanced usual care, GET or prescribed aerobic exercise. The outcome assessment will occur remotely 14–18 weeks following baseline assessment, after completing the 12-week treatment phase. The primary outcome will be symptom severity (Rivermead Post-concussion Symptoms Questionnaire).Ethics and disseminationInformed consent will be obtained from all participants. All study procedures were approved by the local research ethics boards (University of British Columbia Clinical Research Ethics Board, University of Calgary Conjoint Health Research Ethics Board, University Health Network Research Ethics Board—Panel D). Operational approvals were obtained for Vancouver Coastal Health Research Institute and Provincial Health Services Authority. If GET proves effective, we will disseminate the GET treatment manual and present instructional workshops for clinicians.Trial registration numberClinicalTrials.gov #NCT05365776