Development of a vocational rehabilitation intervention to support return-to-work and well-being following major trauma: a person-based approach.

OBJECTIVES: Major trauma centres (MTCs) save lives but rehabilitation to support return-to-work (RTW) is lacking. This paper describes development of a vocational rehabilitation intervention (the ROWTATE intervention) to support RTW following traumatic injury. DESIGN: Sequential and iterative person-based approach in four stages-Stage 1: review of evidence about the efficacy and mechanisms of RTW interventions; Stage 2: interviews (n=38) and focus groups (n=25) with trauma survivors and service providers in five UK MTCs to identify the issues, and challenges faced postinjury; Stage 3: codesign workshops (n=43) with trauma stakeholders in MTCs to conceptually test and identify intervention delivery barriers/enablers; Stage 4: meetings (n=7) with intervention development working group (IDWG) to: (1) generate guiding principles, (2) identify key intervention features (process, components, mechanisms) to address unmet rehabilitation needs; (3) generate a logic model and programme theory to illustrate how the intervention works; and (4) develop a training package to support delivery. RESULTS: Trauma survivors described unmet needs relating to early advice about RTW; psychological support; pain management; hidden disabilities (eg, fatigue); estimating recovery; and community, amputee and musculoskeletal rehabilitation. Mechanisms of effective interventions identified in the review included early intervention, colocation, employer engagement, case coordination and work accommodations. Intervention features identified by IDWG members (n=13) from stages 1 and 2 were use of stepped-care approaches by occupational therapists (OTs) and clinical psychologists (CPs), OT/CP formulation for complex cases, assessment of mental health problems, individually tailored rehabilitation including vocational goal setting, cross-sector coordination/communication, employer engagement, phased RTW, education/advice for family/employers, exploration of work alternatives, ongoing review of physical and mental health needs, work stability monitoring. Conceptual testing ratified the logic model. Geography and long waiting lists were identified as potential delivery barriers. CONCLUSIONS: Real-world testing of the intervention is underway in a randomised controlled trial.

What do employers need when supporting stroke survivors to return to work?: a mixed-methods study.

BACKGROUND: Employers are key in supporting stroke survivors to return to work (RTW) but do not always have knowledge/skills or guidance to do so. OBJECTIVES: To explore employers' needs for provision of post-stroke RTW support. METHODS: Mixed-methods study. Participants recruited through voluntary response/purposive sampling. Survey of employers investigated stroke knowledge (maximum score: 7), RTW process knowledge (maximum score: 8), and perceived competency for actions supporting RTW (maximum score: 100%). Regression analyses explored relationships between employers' demographic/contextual characteristics and knowledge and perceived competency scores. Interviews with employers explored factors influencing their post-stroke RTW support. Interview data were analyzed using a framework analysis. Survey/interview findings were synthesized with those from a qualitative systematic review. RESULTS: Across the survey (n = 50), interviews (n = 7), and review (25 studies), employers' support was influenced by stroke survivors' decisions to disclose stroke-related limitations, employers' knowledge regarding roles/responsibilities, employers' communication skills, and information provided by healthcare. Regression analyses: Human resources/occupational health support was positively associated with stroke knowledge (ß = 2.30, 95% CI 0.36-4.41, p = 0.013) and RTW process knowledge (ß = 5.12, 95% CI 1.80-6.87, p = 0.001). Post-stroke RTW experience was positively associated with stroke knowledge (ß = 1.36, 95% CI 0.46-2.26, p = 0.004) and perceived competency (ß = 31.13, 95% CI 18.40-44.76, p = 0.001). Organization size (i.e. working in a larger organization) was positively associated with RTW process knowledge (ß = 2.96, 95% CI 1.52-4.36, p = <.001). CONCLUSIONS: Employers' RTW support was influenced by personal and environmental factors; they may benefit from education and guidance on stroke and their roles/responsibilities during the RTW process.

Early vocational rehabilitation and psychological support for trauma patients to improve return to work (the ROWTATE trial): study protocol for an individually randomised controlled multicentre pragmatic trial.

BACKGROUND: Moderately severe or major trauma (injury severity score (ISS) > 8) is common, often resulting in physical and psychological problems and leading to difficulties in returning to work. Vocational rehabilitation (VR) can improve return to work/education in some injuries (e.g. traumatic brain and spinal cord injury), but evidence is lacking for other moderately severe or major trauma. METHODS: ROWTATE is an individually randomised controlled multicentre pragmatic trial of early VR and psychological support in trauma patients. It includes an internal pilot, economic evaluation, a process evaluation and an implementation study. Participants will be screened for eligibility and recruited within 12 weeks of admission to eight major trauma centres in England. A total of 722 participants with ISS > 8 will be randomised 1:1 to VR and psychological support (where needed, following psychological screening) plus usual care or to usual care alone. The ROWTATE VR intervention will be provided within 2 weeks of study recruitment by occupational therapists and where needed, by clinical psychologists. It will be individually tailored and provided for ≤ 12 months, dependent on participant need. Baseline assessment will collect data on demographics, injury details, work/education status, cognitive impairment, anxiety, depression, post-traumatic distress, disability, recovery expectations, financial stress and health-related quality of life. Participants will be followed up by postal/telephone/online questionnaires at 3, 6 and 12 months post-randomisation. The primary objective is to establish whether the ROWTATE VR intervention plus usual care is more effective than usual care alone for improving participants' self-reported return to work/education for at least 80% of pre-injury hours at 12 months post-randomisation. Secondary outcomes include other work outcomes (e.g. hours of work/education, time to return to work/education, sickness absence), depression, anxiety, post-traumatic distress, work self-efficacy, financial stress, purpose in life, health-related quality of life and healthcare/personal resource use. The process evaluation and implementation study will be described elsewhere. DISCUSSION: This trial will provide robust evidence regarding a VR intervention for a major trauma population. Evidence of a clinically and cost-effective VR intervention will be important for commissioners and providers to enable adoption of VR services for this large and important group of patients within the NHS. TRIAL REGISTRATION: ISRCTN: 43115471. Registered 27/07/2021.

What affects implementation of the UK major trauma rehabilitation prescription? A survey informed by the behaviour change wheel.

OBJECTIVE: Major trauma 'Rehabilitation Prescriptions' aim to facilitate continuity of care and describe patient needs following discharge from UK Major Trauma Centre (MTCs), however research suggests rehabilitation prescriptions are not being implemented as intended. We aimed to identify factors influencing completion and use of rehabilitation prescriptions using the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). DESIGN: Online survey informed by the TDF and BCW. SETTING: UK trauma rehabilitation pathway. POPULATION: Rehabilitation and trauma service providers involved in completing and/or using rehabilitation prescriptions (n = 78). ANALYSIS: Mean scores were calculated for TDF behavioural domains, identifying facilitators (score ≥5) and barriers (≤3.5) to rehabilitation prescription implementation. Thematic analysis of free text data informed by the BCW/TDF identified further facilitators and barriers, plus potential behaviour change strategies. RESULTS: Most respondents worked in UK MTCs (n = 63) and were physiotherapists (n = 34), trauma rehabilitation coordinators (n = 16) or occupational therapists (n = 15). 'Social/professional role and identity', 'knowledge' and 'emotion' (the highest-scoring TDF domains) were facilitators to implementing rehabilitation prescriptions. Qualitative data identified barriers to rehabilitation prescription completion, including 'seen as tick-box exercise','not a priority', lack of resources (IT and workforce), poor inter-service communication, limited knowledge/training. Facilitators included therapist buy-in, standardised training, easy inter-service rehabilitation prescription transfer, usefulness for sharing patient needs. CONCLUSIONS: Although rehabilitation prescriptions are valued by some service providers, their effectiveness is hindered by negative attitudes, limited knowledge and poor communication. Uncertainties exist about whether rehabilitation prescriptions achieve their goals, particularly in documenting patient needs, engaging patients in rehabilitation, and informing onward referrals following MTC discharge. Improving IT systems, empowering patients, redirecting funding, and providing training might improve their usage. Further research should explore service provider and patient perspectives, and prospective long-term follow-up on outcomes of rehabilitation prescription recommendations.

Investigating the Implementation of Community-Based Stroke Telerehabilitation in England; A Realist Synthesis Study Protocol.

Telerehabilitation (TR) shows promise as a method of remote service delivery, yet there is little guidance to inform implementation in the context of the National Health Service (NHS) in England. This paper presents the protocol for a realist synthesis study aiming to investigate how TR can be implemented to support the provision of high-quality, equitable community-based stroke rehabilitation, and under what conditions. Using a realist approach, we will synthesise information from (1) an evidence review, (2) qualitative interviews with clinicians (n ≤ 30), and patient-family carer dyads (n ≤ 60) from three purposively selected community stroke rehabilitation services in England. Working groups including rehabilitation professionals, service-users and policy-makers will co-develop actionable recommendations. Insights from the review and the interviews will be synthesised to test and refine programme theories that explain how TR works and for whom in clinical practice, and draw key messages for service implementation. This protocol highlights the need to improve our understanding of TR implementation in the context of multidisciplinary, community-based stroke service provision. We suggest the use of a realist methodology and co-production to inform evidence-based recommendations that consider the needs and priorities of clinicians and people affected by stroke.

A Qualitative Study to Understand the Impact of Caring for Traumatic Injury Survivors.

BACKGROUND: Following traumatic injury, an informal carer is often required to support recovery. Understanding the impact of caregiving is important to inform intervention design. AIM: to explore the impact of caring on family and caregiver finances, employment, social life, and psychological wellbeing. METHOD: Semi-structured interviews conducted with carers of traumatic injury survivors. Interviews were audio recorded, transcribed and thematically analysed, informed by the Roy Adaptation Model (RAM) and International Classification of Functioning, Disability and Health (ICF). RESULTS: Ten participants were interviewed. Key themes included (1) financial impact/employment issues, (2) relationships and support and (3) psychological impact. Most carers did not receive professional support with daily care post-discharge. Carers' employers responded positively, supporting them even after extensive leave. Carers received inconsistent communication whilst visiting trauma survivors in hospital; carers with healthcare experience were favoured. Navigating and receiving benefits was complex. Some carers found it difficult to accept the trauma survivor's injury, whilst others focused on achieving goals. CONCLUSIONS: Support from professional services is limited outside hospital settings for non-brain injuries. Future interventions and healthcare services should acknowledge the lack of psychological support for carers. Researchers should consider using the ICF/RAM when designing interventions to ensure the full impact on carers is addressed.

Brain-In-Hand technology for adults with acquired brain injury: A convergence of mixed methods findings.

Introduction: Individuals with acquired brain injury may find it difficult to self-manage and live independently. Brain-in-Hand is a smartphone app designed to support psychological problems and encourage behaviour change, comprised of a structured diary, reminders, agreed solutions, and traffic light monitoring system. Aim: To evaluate the potential use and effectiveness of Brain-in-Hand for self-management in adults with acquired brain injury. Methods: A-B mixed-methods case-study design. Individuals with acquired brain injury (n = 10) received Brain-in-Hand for up to 12 months. Measures of mood, independence, quality of life, cognition, fatigue, goal attainment, participation administered at baseline, 6 and 12 months. Semi-structured interviews conducted with acquired brain injury participants (n = 9) and healthcare workers (n = 3) at 6 months. Results: Significant increase in goal attainment after 6 months use (t(7) = 4.20, p = .004). No significant improvement in other outcomes. Qualitative data suggested improvement in anxiety management. Contextual (personal/environmental) factors were key in influencing the use and effectiveness of Brain-in-Hand. Having sufficient insight, appropriate support and motivation facilitated use. Conclusions: Brain-in-Hand shows potential to support acquired brain injury, but further work is required to determine its effectiveness. Context played a pivotal role in the effectiveness and sustained use of Brain-in-Hand, and needs to be explored to support implementation.

Qualitative study exploring factors affecting the implementation of a vocational rehabilitation intervention in the UK major trauma pathway.

OBJECTIVES: This study aimed to: (1) understand the context for delivering a trauma vocational rehabilitation (VR) intervention; (2) identify potential barriers and enablers to the implementation of a VR intervention post-trauma. DESIGN: Qualitative study. Data were collected in person or via phone using different methods: 38 semistructured interviews, 11 informal 'walk-through care pathways' interviews, 5 focus groups (n=25), 5 codesign workshops (n=43). Data were thematically analysed using the framework approach, informed by the Consolidated Framework for Implementation Research. SETTING: Stakeholders recruited across five UK major trauma networks. PARTICIPANTS: A variety of stakeholders were recruited (n=117) including trauma survivors, rehabilitation physicians, therapists, psychologists, trauma coordinators and general practitioners. We recruited 32 service users (trauma survivors or carers) and 85 service providers. RESULTS: There were several issues associated with implementing a trauma VR intervention including: culture within healthcare/employing organisations; extent to which healthcare systems were networked with other organisations; poor transition between different organisations; failure to recognise VR as a priority; external policies and funding. Some barriers were typical implementation issues (eg, funding, policies, openness to change). This study further highlighted the challenges associated with implementing a complex intervention like VR (eg, inadequate networking/communication, poor service provision, perceived VR priority). Our intervention was developed to overcome these barriers through adapting a therapist training package, and by providing early contact with patient/employer, a psychological component alongside occupational therapy, case coordination/central point of contact, and support crossing sector boundaries (eg, between health/employment/welfare). CONCLUSIONS: Findings informed the implementation of our VR intervention within the complex trauma pathway. Although we understand how to embed it within this context, the success of its implementation needs to be measured as part of a process evaluation in a future trial.

Factors Affecting the Delivery and Acceptability of the ROWTATE Telehealth Vocational Rehabilitation Intervention for Traumatic Injury Survivors: A Mixed-Methods Study.

BACKGROUND: Returning to work after traumatic injury can be problematic. We developed a vocational telerehabilitation (VR) intervention for trauma survivors, delivered by trained occupational therapists (OTs) and clinical psychologists (CPs), and explored factors affecting delivery and acceptability in a feasibility study. METHODS: Surveys pre- (5 OTs, 2 CPs) and post-training (3 OTs, 1 CP); interviews pre- (5 OTs, 2 CPs) and post-intervention (4 trauma survivors, 4 OTs, 2 CPs). Mean survey scores for 14 theoretical domains identified telerehabilitation barriers (score ≤ 3.5) and facilitators (score ≥ 5). Interviews were transcribed and thematically analysed. RESULTS: Surveys: pre-training, the only barrier was therapists' intentions to use telerehabilitation (mean = 3.40 ± 0.23), post-training, 13/14 domains were facilitators. Interviews: barriers/facilitators included environmental context/resources (e.g., technology, patient engagement, privacy/disruptions, travel and access); beliefs about capabilities (e.g., building rapport, complex assessments, knowledge/confidence, third-party feedback and communication style); optimism (e.g., impossible assessments, novel working methods, perceived importance and patient/therapist reluctance) and social/professional role/identity (e.g., therapeutic methods). Training and experience of intervention delivery addressed some barriers and increased facilitators. The intervention was acceptable to trauma survivors and therapists. CONCLUSION: Despite training and experience in intervention delivery, some barriers remained. Providing some face-to-face delivery where necessary may address certain barriers, but strategies are required to address other barriers.

Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury.

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers' expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings.

Vocational rehabilitation to enhance return to work after trauma (ROWTATE): protocol for a non-randomised single-arm mixed-methods feasibility study.

BACKGROUND: Traumatic injuries are common amongst working-age adults. Survivors often experience physical and psychological problems, reduced quality of life and difficulty returning to work. Vocational rehabilitation improves work outcomes for a range of conditions but evidence of effectiveness for those with traumatic injuries is lacking. This study assesses feasibility of delivering a vocational rehabilitation intervention to enhance return to work and improve quality of life and wellbeing in people with at least moderate trauma to inform design of a definitive randomised controlled trial (RCT). METHODS: Non-randomised, single-arm, multi-centre mixed-methods feasibility study with nested case studies and qualitative study. The case studies comprise interviews, observations of clinical contacts and review of clinical records. The qualitative study comprises interviews and/or focus groups. Participants will be recruited from two UK major trauma centres. Participants will comprise 40 patients aged 16-69 with an injury severity score of > 8 who will receive the intervention and complete questionnaires. Interviews will be conducted with 10 patients and their occupational therapists (OTs), clinical psychologists (CPs), employers and commissioners of rehabilitation services. Fidelity will be assessed in up to six patients by observations of OT and CP-patient contacts, review of patient records and intervention case report forms. OT and CP training will be evaluated using questionnaires and competence to deliver the intervention assessed using a team objective structured clinical examination and written task. Patients participating in and those declining participation in the study will be invited to take part in interviews/focus groups to explore barriers and facilitators to recruitment and retention. Outcomes include recruitment and retention rates, intervention fidelity, OT and CP competence to deliver the intervention, experiences of delivering or receiving the intervention and factors likely to influence definitive trial delivery. DISCUSSION: Effective vocational rehabilitation interventions to enhance return to work amongst trauma patients are urgently needed because return to work is often delayed, with detrimental effects on health, financial stability, healthcare resource use and wider society. This protocol describes a feasibility study delivering a complex intervention to enhance return to work in those with at least moderate trauma. TRIAL REGISTRATION: ISRCTN: 74668529 . Prospectively registered on 23 January 20.

A scoping review of psychoeducational interventions for people after transient ischemic attack and minor stroke.

BACKGROUND: Psychoeducation can provide information and support to cope with the physical and emotional effects of a health condition. This scoping review aimed to identify the evidence regarding psychoeducational interventions for people after a Transient Ischemic Attack (TIA) and minor stroke. METHODS: This review was conducted in accordance with the PRISMA Extension for Scoping Reviews. Three electronic databases (MEDLINE, Embase, PsycINFO) were searched for articles on interventions related to psychoeducational support post-TIA and minor/mild stroke. Search retrieved 3722 articles. Three reviewers independently screened titles, abstracts, full-texts, and extracted data for included studies. Study quality was assessed using the JADAD scale. TIDieR checklist was used to describe interventions. RESULTS: Fifteen RCTs were included. Twelve studies were of high quality (JADAD score ≥2), two were of low quality. A total of 1500 participants were recruited across studies. Definition of TIA and minor stroke was unclear, leading to the exclusion of several studies. Various interventions were included, including education/psychoeducation (n = 4); exercise and lifestyle advice (n = 3); telephone-based education/counseling (n = 3); secondary prevention education (n = 1); motivational interviewing (n = 2); self-management (n = 2). Interventions were inconsistently described, with information missing about who delivered it and tailoring. CONCLUSIONS: Definitions of stroke severity are not adequately reported. There are a variety of interventions including education about a range of stroke-specific topics. Many interventions are not adequately described, thus making it difficult to determine if the aim was to provide information or support post-TIA/minor stroke. There is a need for an in-depth systematic review to develop a clear definition of psychoeducation.

A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK.

OBJECTIVE: To identify where and how trauma survivors' rehabilitation needs are met after trauma, to map rehabilitation across five UK major trauma networks, and to compare with recommended pathways. DESIGN: Qualitative study (interviews, focus groups, workshops) using soft-systems methodology to map usual care across trauma networks and explore service gaps. Publicly available documents were consulted. CATWOE (Customers, Actors, Transformation, Worldview, Owners, Environment) was used as an analytic framework to explore the relationship between stakeholders in the pathway. SETTING: Five major trauma networks across the UK. SUBJECTS: 106 key rehabilitation stakeholders (service providers, trauma survivors) were recruited to interviews (n = 46), focus groups (n = 4 groups, 17 participants) and workshops (n = 5 workshops, 43 participants). INTERVENTIONS: None. RESULTS: Mapping of rehabilitation pathways identified several issues: (1) lack of vocational/psychological support particularly for musculoskeletal injuries; (2) inconsistent service provision in areas located further from major trauma centres; (3) lack of communication between acute and community care; (4) long waiting lists (up to 12 months) for community rehabilitation; (5) most well-established pathways were neurologically focused. CONCLUSIONS: The trauma rehabilitation pathway is complex and varies across the UK with few, if any patients following the recommended pathway. Services have developed piecemeal to address specific issues, but rarely meet the needs of individuals with multiple impairments post-trauma, with a lack of vocational rehabilitation and psychological support for this population.

Describing Return to Work after Stroke: A Feasibility Trial of 12-month Outcomes.

OBJECTIVE: Stroke is the greatest cause of disability in adults. A quarter of strokes affect people of working age, yet under half return to work after stroke. There has been little investigation into what constitutes "return to work" following stroke. The aim of this study is to describe the work metrics of stroke survivor participants in a feasibility randomized controlled trial of an early stroke-specific vocational rehabilitation intervention. METHODS: Retrospective analysis of trial data. Metrics on work status, working hours, workplace accommodations and costs were extracted from trial outcomes gathered by postal questionnaire at 3, 6, and 12 months' post-randomization for 46 stroke participants in a feasibility randomized controlled trial. Participants were randomized to receive vocational rehabilitation (intervention) or usual care (control). RESULTS: Two-thirds (n = 29; 63%) of participants returned to work at some point in the 12 months following stroke. Participants took a mean of 90 days to return to work. Most returned to the same role with an existing employer. Only one-third of participants who were employed full-time at stroke onset were working full-time at 12 months post-stroke. Most participants experienced a reduction in pre-stroke earnings. Workplace accommodations were more common among intervention group participants. More intervention participants than control participants reported satisfaction with work at both 6 and 12 months post-randomization.  Conclusion: This study illustrates the heterogeneous nature of return to work and the dramatic impact of stroke on work status, working hours and income. Longitudinal research should explore the socioeconomic legacy of stroke and include clear definitions of work and accurate measures of working hours and income from all sources.

A systematic review of personal smart technologies used to improve outcomes in adults with acquired brain injuries.

OBJECTIVE: This review aimed to determine the effectiveness of personal smart technologies on outcomes in adults with acquired brain injury. DATA SOURCES: A systematic literature search was conducted on 30 May 2019. Twelve electronic databases, grey literature databases, PROSPERO, reference list and author citations were searched. METHODS: Randomised controlled trials were included if personal smart technology was used to improve independence, goal attainment/function, fatigue or quality of life in adults with acquired brain injury. Data were extracted using a bespoke form and the TIDieR checklist. Studies were graded using the PEDro scale to assess quality of reporting. Meta-analysis was conducted across four studies. RESULTS: Six studies met the inclusion criteria, generating a total of 244 participants. All studies were of high quality (PEDro ⩾ 6). Interventions included personal digital assistant, smartphone app, mobile phone messaging, Neuropage and an iPad. Reporting of intervention tailoring for individual needs was inconsistent. All studies measured goal attainment/function but none measured independence or fatigue. One study (n = 42) reported a significant increase in memory-specific goal attainment (p = 0.0001) and retrospective memory function (p = 0.042) in favour of the intervention. Another study (n = 8) reported a significant increase in social participation in favour of the intervention (p = 0.01). However, our meta-analyses found no significant effect of personal smart technology on goal attainment, cognitive or psychological function. CONCLUSION: At present, there is insufficient evidence to support the clinical benefit of personal smart technologies to improve outcomes in acquired brain injury. Researchers need to conduct more randomised studies to evaluate these interventions and measure their potential effects/harms.

Informing evaluation of a smartphone application for people with acquired brain injury: a stakeholder engagement study.

BACKGROUND: Brain in Hand is a smartphone application (app) that allows users to create structured diaries with problems and solutions, attach reminders, record task completion and has a symptom monitoring system. Brain in Hand was designed to support people with psychological problems, and encourage behaviour monitoring and change. The aim of this paper is to describe the process of exploring the barriers and enablers for the uptake and use of Brain in Hand in clinical practice, identify potential adaptations of the app for use with people with acquired brain injury (ABI), and determine whether the behaviour change wheel can be used as a model for engagement. METHODS: We identified stakeholders: ABI survivors and carers, National Health Service and private healthcare professionals, and engaged with them via focus groups, conference presentations, small group discussions, and through questionnaires. The results were evaluated using the behaviour change wheel and descriptive statistics of questionnaire responses. RESULTS: We engaged with 20 ABI survivors, 5 carers, 25 professionals, 41 questionnaires were completed by stakeholders. Comments made during group discussions were supported by questionnaire results. Enablers included smartphone competency (capability), personalisation of app (opportunity), and identifying perceived need (motivation). Barriers included a physical and cognitive inability to use smartphone (capability), potential cost and reliability of technology (opportunity), and no desire to use technology or change from existing strategies (motivation). The stakeholders identified potential uses and changes to the app, which were not easily mapped onto the behaviour change wheel, e.g. monitoring fatigue levels, method of logging task completion, and editing the diary on their smartphone. CONCLUSIONS: The study identified that both ABI survivors and therapists could see a use for Brain in Hand, but wanted users to be able to personalise it themselves to address individual user needs, e.g. monitoring activity levels. The behaviour change wheel is a useful tool when designing and evaluating engagement activities as it addresses most aspects of implementation, however additional categories may be needed to explore the specific features of assistive technology interventions, e.g. technical functions.

A conditioned response as a measure of impulsive-compulsive behaviours in Parkinson's disease.

OBJECTIVES: Parkinson's Disease patients wore a device on the wrist that gave reminders to take levodopa and also measured bradykinesia and dyskinesia. Consumption of medications was acknowledged by placing the thumb on the device. Some patients performed this acknowledgement repeatedly and unconsciously. This study examines whether this behaviour reflected increased impulsivity. METHODS AND RESULTS: Twenty five participants were selected because they had i) excess acknowledgements described above or ii) Impulsive-Compulsive Behaviours or iii) neither of these. A blinded assessor applied clinical scales to measure Impulsive-Compulsive Behaviours, cognition, depression, anxiety and apathy. A Response Ratio, representing the number of acknowledgements/number of doses (expressed as a percentage) was tightly correlated with ratings of Impulsive-Compulsive Behaviours (r²â€Š= 0.79) in 19/25 subjects. Some of these patients had dyskinesia, which was higher with extraneous responses than with response indicating medication consumption. Six of the 25 subjects had high Impulsive-Compulsive Behaviour Scores, higher apathy scores, low levels of dyskinesia and normal Response Ratios. Patients without ICB (low RR) also had low dyskinesia levels regardless of the relevance of the response. CONCLUSION: An elevated Response Ratio is a specific measure of a type of ICB where increased incentive salience is attributed to cues by the presence of high striatal dopamine levels, manifested by high levels of dyskinesia. This study also points to a second form of ICBs which occur in the absence of dyskinesia, has normal Response Ratios and higher apathy scores, and may represent prefrontal pathology.