Content of clinicians' communication with patients suffering from spinal pain in assessment situations in a specialized spine center: A qualitative study evaluating psychologically informed pain assessments before and after clinicians' participation in an Acceptance and Commitment Therapy course.

INTRODUCTION: Assessment is an important part of chronic pain rehabilitation and should be conducted in line with the current biopsychosocial conceptualization of pain to capture the subjectivity and context of pain. However, pain assessment is commonly conducted from a biomedical framework. A course in Acceptance and Commitment Therapy (ACT) was provided to spinal pain clinicians as a framework to promote more person-centered and psychosocially focused assessments and related psychologically informed practices. The purpose of this qualitative study was to explore the verbal content of clinicians' communication with patients experiencing spinal pain in assessment situations before and after clinicians participated in an ACT course. METHODS: Pain assessments of patients with chronic low back pain conducted by six spinal pain clinicians from different professions were audio-recorded and transcribed. This was done before and after participation in an eight-day ACT course with four following supervisions. A thematic analysis was carried out by two authors across all material, and a comparison of the applied number of codes pre-course and post-course was carried out as an indicator of change. RESULTS: Data consisted of transcripts from the six clinicians across 23 different patients (12 before course participation). Through analysis, 11 codes were developed, which were clustered in three overarching themes: Psychological domains, Communication Techniques, and Intervention Elements. Overall, there was an increase in the application of many of the codes in the transcripts from pre-course to post-course, however with large differences across codes. Increases were primary related to the discussion of life values and value-based action and quality of life as well as the employment of mirroring, challenging beliefs and assumptions, and addressing coping and pacing. CONCLUSIONS: While not the case for all factors, the present findings indicate an increase in including psychological factors and employing interpersonal communication skills after a course in ACT. However, it remains unknown due to the design if the changes reported in this study reflect a clinically valuable change and whether they are due to the ACT training itself. Future research will improve our understanding of the effectiveness of this type of intervention in assessment practices.

Adherence and characteristics of participants enrolled in a standardised programme of patient education and exercises for low back pain, GLA:D® Back - a prospective observational study.

BACKGROUND: Low back pain is often long-lasting, and implementation of low-cost interventions to improve care and minimise its burden is needed. GLA:D® Back is an evidence-based programme consisting of patient education and supervised exercises for people with low back pain, which was implemented nationwide in primary care clinics in Denmark. To assess how the intervention was received and factors influencing adherence to the program, we aimed to evaluate participants' adherence to the intervention and identified characteristics related to the completion of GLA:D® Back. Specifically, we investigated: 1) level of attendance of participants enrolled in the programme, and 2) participant-related factors associated with low attendance. METHODS: Primary care clinicians delivered GLA:D® Back, a standardised 10-week programme of 2 educational and 16 supervised exercise sessions, to patients with low back pain. Attendance was defined as low, medium or high based on self-reported number of attended sessions. Additional participant-reported data included demographic characteristics, pain, prognostic risk profiles, self-efficacy, illness-beliefs, function and clinician-reported physical performance tests. Results for high, medium, low, and unknown attendance were reported descriptively. Odds ratios for low attendance compared to medium/high attendance were calculated by including all baseline factors in a mixed-model logistic regression model. RESULTS: Of 1730 participants, 52% had high, 23% medium, and 25% low levels of attendance. Level of attendance was not strongly associated with participants' individual factors, but in combination, prediction of low attendance was fair (AUC 0.77; 95% CI 0.74-0.79). The strongest indicator of low attendance was not completing the baseline questionnaire. CONCLUSIONS: Most participants of a 10-week low back pain programme attended almost all session. Non-response to the baseline questionnaire was strongly associated with low attendance, whereas individual patient characteristics were weakly related to attendance. Not completing baseline questionnaires might be an early indicator of poor adherence in programs for people with persistent low back pain. TRIAL REGISTRATION: The Health Research Ethics for Southern Denmark decided there was no need for ethical approval (S-20172000-93). The Danish data collection has obtained authorisation from the Danish Data Protection Agency as part of the University of Southern Denmark's institutional authorisation (DPA no. 2015-57-0008 SDU no. 17/30591). The trial was registred at ClinicalTrials.gov NCT03570463 .

There's Nothing Broken. You've Had a Whiplash, That's It: A Qualitative Study of Comorbid Posttraumatic Stress Disorder and Whiplash Associated Disorders.

BACKGROUND: Posttraumatic stress disorder (PTSD) symptoms are common in chronic Whiplash associated disorders (WAD) and have been found to be associated with higher levels of pain and disability. Theoretical frameworks have suggested that PTSD and pain not only coexist, but also mutually maintain one another. Although the comorbidity has been subject to increasing quantitative research, patients' experiences of the comorbidity and symptom interaction remain largely uninvestigated using qualitative methods. OBJECTIVE: The present study set out to explore the potential relationship of PTSD and pain in people with WAD and properly assessed PTSD after motor vehicle accidents. METHODS: A qualitative explorative study of eight individual face-to-face semistructured interviews were conducted. Interviews were recorded and transcribed verbatim and analyzed using framework analysis. RESULTS: Through the analysis, we developed three overarching themes. The first theme illustrated the complex and burdensome comorbidity with overlapping and transdiagnostic symptoms, whereas the second theme highlighted how several circumstances, some related to the health care system, could extend and amplify the traumatic response. The final theme illustrated symptom associations and interactions, particularly between pain and PTSD, both supporting and rejecting parts of the mutual maintenance framework. CONCLUSIONS: These findings underlined the great complexity and variability of the comorbidity and the traumatic event, but also emphasized how experiences of psyche and soma seem closely connected in these patients. The results provide support for the importance of thorough assessment by multidisciplinary teams, minimizing distress post-injury, and a critical approach to the idea of mutual maintenance between pain and PTSD.

The associations of acceptance with quality of life and mental health following spinal cord injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: To identify, critically appraise, and synthesize research findings on the associations between acceptance, quality of life (QOL), and mental health outcomes in individuals living with spinal cord injury (SCI). METHODS: Five databases (PubMed, PsycINFO, Embase, Web of Science, and Scopus) were systematically searched. Studies were included if they provided findings on the association between acceptance and QOL, mental health outcomes, or both in an SCI population aged 16 years or older. Only peer-reviewed original quantitative and qualitative studies were included. Screening, quality assessment, and data extraction were conducted independently by two researchers. Findings were tabulated and synthesized by outcome. RESULTS: Forty-one studies were included. Greater acceptance was consistently associated with greater global and psychological QOL, life satisfaction, sense of well-being, mental health, and with lower levels of depression and anxiety. Inconsistent evidence was found with regards to social QOL and post-traumatic stress disorder. Acceptance was generally not associated with adjustment outcomes further than 2 years into the future. Study quality of the quantitative studies was mostly fair (n = 17) followed by good (n = 13), and poor (n = 9). CONCLUSION: Health-care professionals may regard acceptance as a psychological resource they can aim to support in improving QOL and mental health following SCI. A range of methodological and conceptual limitations were present in the research. Future studies should prioritize longitudinal designs, consider dyadic effects, explore subjective meaning(s) of acceptance, and investigate the effectiveness of therapeutic approaches that stimulate the acceptance process.

Pain-Related Acceptance as a Mediator in the Fear Avoidance Model of Chronic Pain: A Preliminary Study.

Objective: The fear avoidance model has served as a popular, heuristic model in explaining the transition from acute to chronic pain. In addition, the significance of pain-related acceptance in chronic pain development and adjustment is underlined in a vast number of empirical studies. The objective of the current preliminary study was to investigate pain-related acceptance as a mediator within the key cognitive relationships proposed by the fear avoidance model of chronic pain. Materials and Methods. In a cross-sectional design, bodily pain, pain catastrophizing, fear avoidance beliefs, and pain-related acceptance were assessed by questionnaires in 125 chronic pain patients in a Danish multidisciplinary pain center. Mediation analyses were performed to test the effect of pain-related acceptance on bodily pain, pain catastrophizing, and fear avoidance beliefs. Results: Medium-sized correlations were found between all outcomes. Mediation analyses revealed that pain-related acceptance was a significant mediator between 1) bodily pain and pain catastrophizing and 2) pain catastrophizing and fear avoidance beliefs after controlling for bodily pain. Furthermore, pain-related acceptance accounted for a large proportion in both associations (82.2% and 56.1%). Conclusions: The results suggest that pain-related acceptance is a prominent psychological mechanism within the key cognitive associations of the fear avoidance model, which predicts a certain path of cognitive, emotional, and behavioral factors in the development and maintenance of chronic pain. This proposes pain-related acceptance to be an important mechanism that possibly counteracts the negative reactions of pain catastrophizing and fear avoidance beliefs. These findings should be investigated further and could potentially be an important place to intervene clinically in order to counteract the development and/or maintenance of chronic pain.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence.

BACKGROUND: Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain. METHODS: GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created. RESULTS: Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions. CONCLUSION: From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Somatic experiencing® for patients with low back pain and comorbid posttraumatic stress disorder - protocol of a randomized controlled trial.

BACKGROUND: Research has almost exclusively focused on the neck in order to explain the mechanisms of persistent pain after motor vehicle collisions (MVC). However, studies have shown that low back pain after MVC is as common as neck pain. Also, posttraumatic stress disorder (PTSD) is common after MVCs, and evidence indicate that PTSD may be linked to the development of pain and disability. PTSD has even been proposed as "the missing link" for some in the development of chronic low back pain. Unfortunately, PTSD often goes unattended in low back pain rehabilitation and very few randomized controlled studies exists targeting both conditions. Hence, the aim of the present study is to investigate the potential additional effect of the trauma therapy "Somatic Experiencing®" (SE) in addition to physiotherapy (PT) compared to PT alone for patients with chronic low back pain and comorbid PTSD. METHODS: The study is a two-group randomized controlled clinical trial in which participants (n = 140) are recruited consecutively from a large Danish spine center in the Region of Southern Denmark, between January 2016 and December 2017. Patients are randomly allocated to one of the two conditions: SE + PT or PT alone. Measurements of effect are carried out at baseline before randomization, post-intervention, 6 and 12 months post-randomization. The primary outcome is a 20% reduction in disability (Rolland Morris Disability Questionnaire) at 6 months post-randomization. Secondary outcomes are: PTSD symptoms, pain intensity, pain-catastrophizing, fear of movement, anxiety and depression. DISCUSSION: Comorbid PTSD is currently not targeted in back pain rehabilitation although highly prevalent. If the SE intervention shows to have an additional effect on disability and pain, the study is likely to have a positive impact on the management of chronic low back pain and will have immediate clinical applicability. TRIAL REGISTRATION: Current Controlled Trials Registration August 4, 2017: NCT03244046 . Retrospectively registered.

A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls.

BACKGROUND: Eradication of pain is seldom an option in chronic pain management. Hence, mindfulness meditation has become popular in pain management. OBJECTIVE: This pilot study compared the effect of a 13-weeks cognitive behavioural therapy program with integrated mindfulness meditation (CBTm) in patients with chronic non-malignant pain with a control condition. It was hypothesised that the CBTm program would reduce pain intensity and psychological distress compared to the control condition and that level of mindfulness and acceptance both would be associated with the reduction in pain intensity and psychological distress. METHODS: A case-control design was used and data were collected from a convenience sample of 70 patients with chronic non-malignant pain. Fifty patients were consecutively recruited to the CBTm intervention and 20 patients matched waiting list controls. Assessments of clinical pain and psychological distress were performed in both groups at baseline and after 13 weeks. RESULTS: The CBTm program reduced depression, anxiety and pain-catastrophizing compared with the control group. Increased level of mindfulness and acceptance were associated with change in psychological distress with the exception of depression, which was only associated with change in level of mindfulness. Surprisingly, changes in level of mindfulness did not correlate with changes in acceptance. CONCLUSIONS: The results indicate that different mechanisms are targeted with cognitive behavioural therapy and mindfulness. The finding that changes in level of mindfulness did not correlate with changes in acceptance may indicate that acceptance is not a strict prerequisite for coping with pain related distress.

Value-based cognitive-behavioural therapy for the prevention of chronic whiplash associated disorders: protocol of a randomized controlled trial.

BACKGROUND: Whiplash injury is the most common traffic-related injury affecting thousands of people every year. Conservative treatments have not proven effective in preventing persistent symptoms and disability after whiplash injury. Early established maladaptive pain behaviours within the first weeks after the injury may explain part of the transition from acute to chronic whiplash associated disorder (WAD). Hence, early targeting of psychological risk factors such as pain catastrophizing, fear-avoidance-beliefs, depression, and symptoms of posttraumatic stress disorder (PTSD) may be important in preventing the development of chronic WAD. Some evidence exists that targeting fear-avoidance beliefs and PTSD with exposure strategies and value-based actions may prevent development of persistent disability after whiplash injury. Yet, the results have to be tested in a randomized controlled trial (RCT). The primary objective of the present study is to test whether a specifically tailored value-based cognitive-behavioural therapy program (V-CBT) is able to prevent the development of persistent disability, pain, and psychological distress if delivered within the first three months after a whiplash injury. METHODS/DESIGN: The current study is a two-armed randomized controlled study with a crossover design. Group A is scheduled for V-CBT within one week of randomization and group B with a delayed onset 3 months after randomization. DISCUSSION: If the study detects significant effects of V-CBT as a preventive intervention, the study will provide new insights of preventive treatment for patients with WAD and thereby serve as an important step towards preventing the chronic condition. TRIAL REGISTRATION: Current Controlled Trials Registration September 19, 2014: NCT02251028.

PTSD Symptoms Mediate the Effect of Attachment on Pain and Somatisation after Whiplash Injury.

INTRODUCTION: The development of persistent pain post-whiplash injury is still an unresolved mystery despite the fact that approximately 50% of individuals reporting whiplash develop persistent pain. There is agreement that high initial pain and PTSD symptoms are indicators of a poor prognosis after whiplash injury. Recently attachment insecurity has been proposed as a vulnerability factor for both pain and PTSD. In order to guide treatment it is important to examine possible mechanisms which may cause persistent pain and medically unexplained symptoms after a whiplash injury. AIM: The present study examines attachment insecurity and PTSD symptoms as possible vulnerability factors in relation to high levels of pain and somatisation after sub-acute whiplash injury. METHODS: Data were collected from 327 patients (women = 204) referred consecutively to the emergency unit after acute whiplash injury. Within 1-month post injury, patients answered a questionnaire regarding attachment insecurity, pain, somatisation, and PTSD symptoms. Multiple mediation analyses were performed to assess whether the PTSD symptom clusters mediated the association between attachment insecurity, pain, and somatisation. RESULTS: A total of 15% fulfilled the DSM-IV symptom cluster criteria for a possible PTSD diagnosis and 11.6% fulfilled the criteria for somatisation. PTSD increased the likelihood of belonging to the moderate-severe pain group three-fold. In relation to somatisation the likelihood of belonging to the group was almost increased four-fold. The PTSD symptom clusters of avoidance and hyperarousal mediated the association between the attachment dimensions, pain, and somatisation. CONCLUSION: Acknowledging that PTSD is part of the aetiology involved in explaining persistent symptoms after whiplash, may help sufferers to gain early and more suited treatment, which in turn may prevent the condition from becoming chronic.

Interpretation of the Patient Health Questionnaire 9 in High-Impact Chronic Pain: Do We Measure Depressive Symptoms the Way We Think?

OBJECTIVES: Depression is prevalent among patients with chronic pain and may impact pain management. An accurate assessment is, however, complicated by overlapping symptoms. This study investigated how patients with high-impact chronic pain interpreted and responded to the Patient Health Questionnaire 9 (PHQ-9) to identify problematic items and causes hereof. MATERIALS AND METHODS: Cognitive interviews using the Three-Step Test-Interview procedure were conducted during the completion of the PHQ-9 in 33 patients with high-impact chronic pain referred to interdisciplinary treatment. Responses were analyzed using 4 coding categories: (1) "congruent" (response consistent with intention); (2) "incongruent" (response not consistent intention); (3) "ambiguous" (response both congruent and incongruent or insufficient to evaluate congruency); and (4) "confused" (response with confused or misunderstood statements). Next, the content of responses to problematic items was analyzed to identify causes for noncongruency, and encountered response difficulties were identified across all items. RESULTS: Three items (items 2, 6, and 9) performed as intended (>97% congruent responses), while 7 items (items 1, 3, 4, 5, 7, 8, and 10) were identified as problematic (<50% congruent responses). Problematic items had 1 or more issues: Responses were based on (1) pain-related issues or (2) other (non-pain) factors unrelated to depression, or item structure caused response difficulties due to wordings, reversion, or having 2 questions in 1. DISCUSSION: Problematic items limit the construct validity of the PHQ-9, leaving an increased risk of inflated depression scores in high-impact chronic pain. Identified problems should guide future revisions to enhance validity and screening accuracy for the benefit of both research and clinical practice.

Validation of the Danish PTSD Checklist for DSM-5 in trauma-exposed chronic pain patients using the Clinician-Administered PTSD Scale for DSM-5.

Background: Validation of post-traumatic stress disorder (PTSD) screening tools across various populations to ensure accurate PTSD estimates is important. Because of the high symptom overlap between PTSD and pain, it is particularly important to validate PTSD screening tools in trauma-exposed chronic pain patients.Objective: The present study is the first seeking to validate the PTSD Checklist for DSM-5 (PCL-5) in a sample of trauma-exposed, treatment-seeking chronic pain patients.Method: The validation and optimal scoring of the PCL-5 were investigated using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in chronic pain patients exposed to traffic or work-related traumas (n = 84). Construct validity was investigated using confirmatory factor analyses testing six competing DSM-5 models in a sample of mixed trauma-exposed chronic pain patients (n = 566), and a subsample of chronic pain patients exposed to traffic or work-related trauma only (n = 202). Furthermore, concurrent validity and discriminant validity were investigated using correlation analysis.Results: The results showed moderate (κ = .46) diagnostic consistency between the PCL-5 and the CAPS-5 using the DSM-5 symptom cluster criteria, and the overall accuracy of the scale (area under the curve = .79) was highly acceptable. Furthermore, the Danish PCL-5 showed excellent construct validity both in the full sample and in the subsample of traffic and work-related accidents, with superior fit of the seven-factor hybrid model. Excellent concurrent validity and discriminant validity were also established in the full sample.Conclusion: The PCL-5 appears to have satisfactory psychometric properties in trauma-exposed, treatment-seeking chronic pain patients.

The present study is the first seeking to validate the PCL-5 using the CAPS-5 in chronic pain patients following traffic and work-related injury.The results showed moderate diagnostic consistency and acceptable overall accuracy using the DSM-5 criteria.Excellent construct, concurrent, and discriminant validity was established in chronic pain patients following mixed traumatic exposure and traffic and work-related trauma only.

Defining a Treatment Model for Self-Management of Fatigue in Rehabilitation of Acquired Brain Injury Using the Rehabilitation Treatment Specification System.

Systematic treatment descriptions to standardize and evaluate management of fatigue after acquired brain injury (ABI) are lacking. The purpose of this multi-phase qualitative study was to formulate a treatment model for promoting self-management of fatigue in rehabilitation of ABI based on practice-based understandings and routines. The study was conducted in a community-based rehabilitation center in Denmark. The model was defined using the Rehabilitation Treatment Specification System. Phase 1 comprised co-production workshops with five service providers (occupational therapists, physiotherapists, and a neuropsychologist) to elicit preliminary treatment theories. In Phase 2, four case studies were conducted on management of fatigue in vocational rehabilitation. Interviews (n = 8) and treatment log entries (n = 76) were analyzed thematically to specify treatment targets and active ingredients. The treatment model comprised five main components: (i) Knowledge and understanding of fatigue, (ii) Interoceptive attention of fatigue, (iii) Acceptance of fatigue, (iv) Activity management, and (v) Self-management of fatigue. For each component, lists of targets and active ingredients are outlined. In conclusion, management of fatigue includes multiple treatment components addressing skills, habits, and mental representations such as knowledge and attitudes. The model articulates treatment theories, which may guide clinical reasoning and facilitate future theory-driven evaluation research.

Relations between PTSD symptom clusters and pain in three trauma-exposed samples with pain.

OBJECTIVES: Little is known about how the individual PTSD symptom clusters relate to intensity and interference of pain and whether these relationships differ across clinical groups. The present study examines relations between PTSD symptom clusters and pain in three trauma-exposed, unique clinical groups: 1) adults seeking treatment for chronic pain with current symptoms of PTSD, 2) trauma affected refugees seeking treatment for PTSD and chronic pain; and 3) individuals identified at admission to the emergency ward after whiplash injury. METHODS: Network analysis was used to assess unique relations between pain intensity, pain interference, re-experiencing, avoidance, numbing, hyperarousal, depression, and anxiety separately in each sample. Links between PTSD clusters and pain were then compared within and between samples. RESULTS: No within-group differences were identified for the links between pain and any of PTSD clusters in the chronic pain and refugee groups. In the whiplash group, hyperarousal was more strongly related to pain than re-experiencing, avoidance, and numbing. Between group comparisons revealed a more pronounced relationship between hyperarousal and pain in the whiplash group, with no between-group differences between the chronic pain and refugee groups. CONCLUSIONS: The findings suggest that when depression and anxiety are accounted for, few unique associations are found between pain and the PTSD symptom clusters in trauma-exposed samples with pain, with the exception of a link between pain and hyperarousal in individuals with whiplash-related PTSD symptoms.

Investigating the DSM-5 and the ICD-11 PTSD symptoms using network analysis across two distinct samples.

OBJECTIVE: Posttraumatic stress disorder (PTSD) has long been debated with a recent focus on the consequences of having two different diagnostic descriptions of PTSD (i.e., the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition [DSM-5] and the International Classification of Diseases-11th Edition [ICD-11]). Research has modeled PTSD as a network of interacting symptoms according to both diagnostic systems, but the relations between the two systems remain unclear regarding which symptoms are more central or interconnected. To answer this question, the present study is the first study to investigate the combined network structure of PTSD symptoms according to both systems using validated measurements (i.e., the International Trauma Questionnaire [ITQ] and the Posttraumatic Stress Disorder Checklist 5 [PCL-5] across two distinct trauma samples [a community sample, N = 2,367], and a military sample, N = 657). METHOD: We estimated two Gaussian Graphical Models of the combined ICD-11 and DSM-5 PTSD symptoms across the two samples. RESULTS: Five of the six most central symptoms were the same across both samples. CONCLUSIONS: The results underline that a combination of five symptoms representing both diagnostic systems may hold central positions and potentially be important for treatment. However, the implications depend on if the different diagnostic descriptions can be reconciled in an indexical rather than constitutive perspective. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measurement Properties of the Dutch Multifactor Fatigue Scale in Early and Late Rehabilitation of Acquired Brain Injury in Denmark.

Fatigue is a major issue in neurorehabilitation without a gold standard for assessment. The purpose of this study was to evaluate measurement properties of the five subscales of the self-report questionnaire the Dutch Multifactor Fatigue Scale (DMFS) among Danish adults with acquired brain injury. A multicenter study was conducted (N = 149, 92.6% with stroke), including a stroke unit and three community-based rehabilitation centers. Unidimensionality and measurement invariance across rehabilitation settings were tested using confirmatory factor analysis. External validity with Depression Anxiety Stress Scales (DASS-21) and the EQ-5D-5L was investigated using correlational analysis. Results were mixed. Unidimensionality and partial invariance were supported for the Impact of Fatigue, Mental Fatigue, and Signs and Direct Consequences of Fatigue, range: RMSEA = 0.07-0.08, CFI = 0.94-0.99, ω = 0.78-0.90. Coping with Fatigue provided poor model fit, RMSEA = 0.15, CFI = 0.81, ω = 0.46, and Physical Fatigue exhibited local dependence. Correlations among the DMFS, DASS-21, and EQ-5D-5L were in expected directions but in larger magnitudes compared to previous research. In conclusion, three subscales of the DMFS are recommended for assessing fatigue in early and late rehabilitation, and these may facilitate the targeting of interventions across transitions in neurorehabilitation. Subscales were strongly interrelated, and the factor solution needs evaluation.

Using the Multidimensional Model of Acceptance to Investigate How Different Facets of Acceptance are Related to Quality of Life Following Spinal Cord Injury.

OBJECTIVE: To determine how different facets of acceptance are related to quality of life (QoL) following spinal cord injury, after controlling for sociodemographic factors, injury-related variables, depression, and anxiety. PARTICIPANTS: Adults with spinal cord injury. METHODS: Questionnaires were completed via research electronic data capture (REDCap). Three separate hierarchical multivariate linear regression analyses were performed, with physical QoL, psychological QoL, and global QoL as outcomes. Sex, age, time since injury, depression, anxiety, and 4 facets of acceptance (i.e. "accepting reality", "valuechange", "letting go of control" and "behavioural engagement") were independent variables. RESULTS: Of the 686 eligible participants, 453 responded (66.0%). The sample included 303 men (66.9%), mean (standard deviation; SD) age 56.6 (15.0) years and mean (standard deviation) time since injury 14.6 (11.4) years. The final regression models (n = 376) explained 46% of global QoL, 47% of psychological QoL and 31% of physical QoL. The 4 facets of acceptance significantly increased the amount of variance explained by 6% for psychological QoL, 8% for physical QoL and 14% for global QoL. The facets "value-change" and "behavioural engagement" made significant contributions to all domains of QoL, while "letting go of control" only contributed to global QoL, and "accepting reality" only contributed to psychological QoL. CONCLUSION: Acceptance may support higher QoL in more ways than simply reducing psychological distress, and could be an important process to facilitate in rehabilitation after spinal cord injury.

Values-based cognitive behavioural therapy for the prevention of chronic whiplash associated disorders: A randomized controlled trial.

BACKGROUND: Whiplash is a common traffic-related injury with up to 50% of those affected continuing to experience symptoms one-year post-injury. Unfortunately, treatments have not proven highly effective in preventing and treating chronic symptomatology. The overall aim of this study was to test the effectiveness of an early values-based cognitive-behavioural therapeutic intervention (V-CBT) delivered within 6 months post-injury in preventing chronic symptomatology compared to wait list controls. METHODS: The study was a two-armed randomized controlled trial. Participants (n = 91) experienced pain, disability and at least one psychological risk factor (e.g. enhanced pain-catastrophizing) after a whiplash trauma no later than 6 months prior. Participants were randomized to 10 sessions of V-CBT starting 1 week (group A) or 3 months (group B) post-randomization. The primary outcome was pain-related disability, while secondary outcomes were pain intensity, neck-pain related disability, depression, anxiety, PTSD symptoms, pain-catastrophizing and kinesiophobia. These were evaluated at baseline and at 3, 6, 9 and 12 months post-randomization. RESULTS: At 3 months, group A demonstrated clinically important effects on all outcomes that were significantly better than group B (waitlist). When group B received the intervention at 6 months, they also demonstrated clinically important effects on all outcomes. However, there was a significant difference at 12 months for the primary outcome, in which group B increased their disability levels, while group A remained stable. CONCLUSIONS: While this indicates that an intervention window for early prevention of disability after whiplash injury may exist, this needs to be tested in a truly early intervention. SIGNIFICANCE: An early Values-based Cognitive Behavioural Therapeutic intervention delivered within 6 months post-injury (mean days 117) was effective in reducing pain-related disability and psychological distress compared to the control group that received the intervention later after a three months wait-list period. The effects were sustained at 12 months follow-up. The early intervention was significantly more effective in reducing pain-related disability compared to the control group, indicating that an intervention window for early prevention of disability after whiplash injury may exist.

The Wildman Programme - Experiences from a first implementation of a nature-based intervention designed for men with stress and chronic illnesses.

BACKGROUND AND PURPOSE: In Denmark attractive rehabilitation offers for men are lacking. Consequently, more men than women say no to participate in and more often drop out of rehabilitation programs. Therefore, a nature-based rehabilitation program called the 'Wildman Programme' has been designed to men. The 'Wildman Programme' combines nature experiences, body awareness training, mind relaxation, and supporting community spirit. The method is called Nature-Body-Mind-Community (NBMC). The aim of this study was to assess the implementability and effect of the 'Wildman Programme' on the participants' quality of life and symptoms of stress. MATERIALS AND METHODS: The 'Wildman Programme' was explored as a quasi-experimental study. The study included 20 men with psychological stress and diminished quality of life due to mental health challenges and chronic illnesses. The primary outcome was quality of life and the secondary outcome was stress level. All outcomes were measured at baseline (T1) and at the end of the 'Wildman Programme' (T2). RESULTS: The study showed the 'Wildman Programme' has potential to reduce stress symptoms (15.40%) and enhance quality of life (10.07%) among the male participants. Furthermore, physical health (13.92%) and psychological health (16.88%) in relation to quality of life increased during the program. CONCLUSION: The study showed that the 'Wildman Programme' is implementable in a Danish healthcare center. It was well received by the health professionals and the method was in demand by the target group of men. However, a larger study should be conducted to further investigate the findings of this study.

The effect of medical cannabis on cognitive functions: a systematic review.

BACKGROUND: Cannabis-based medicines are widely used in the treatment of a number of medical conditions. Unfortunately, cognitive disturbances are often reported as adverse events, although conversely, cognitive improvements have been reported. Hence, the objective of the present study was to identify, critically appraise and synthesise research findings on the potential impact of cannabis-based medicines on cognitive functioning. METHODS: Four databases (EMBASE, PsycINFO, PubMed and Scopus) were systematically searched. Studies were included if they provided findings on the impact of cannabis-based medicines in controlled settings on cognitive functioning measured by recognised cognitive tests in human adults. Study participants were required to be their own case-control, and neither studies on abuse, abstinences, patients with severe neurodegenerative diseases nor cancer-related pain conditions were included. Screening, risk of bias assessment and data extraction were conducted independently by two researchers. Findings were tabulated and synthesised by outcome. FINDINGS: Twenty-three studies were included, comprising a total of N = 917. Eight studies used Sativex as the cannabis-based medicine two used Epidiolex, two other studies used sprays, three studies used gelatine capsules, five smoked cannabis, two other and finally one studied cannabis withdrawal. Fifteen studies reported non-significant findings; six reported cognitive impairments; one study found cognitive improvement and a single study found improvement following withdrawal. Thirteen studies had cognitive or neuropsychological functioning as the primary outcome. CONCLUSIONS: Due to a large heterogeneity and methodological limitations across studies, it is not possible to make any definite conclusions about the impact of cannabis-based medicines on cognitive functioning. However, the majority of high-quality evidence points in the direction that the negative impact of cannabis-based medicines on cognitive functioning is minor, provided that the doses of THC are low to moderate. On the other hand, long-term use of cannabis based medicines may still adversely affect cognitive functioning. In the studies that found impaired cognitive functioning to be significant, all of the test scores were either within the normal range or below what would be characterised as a neuropsychologically cognitive impairment.