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INTRODUCTION: Persistent 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 ANALYSIS: We 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 DISSEMINATION: Informed 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 NUMBER: ClinicalTrials.gov #NCT05365776.
Subject(s)
Brain Concussion , Fear , Implosive Therapy , Humans , Brain Concussion/therapy , Brain Concussion/psychology , Fear/psychology , Canada , Implosive Therapy/methods , Avoidance Learning , Quality of Life , Randomized Controlled Trials as Topic , Post-Concussion Syndrome/therapy , Post-Concussion Syndrome/psychology , Male , Multicenter Studies as Topic , Adult , FemaleABSTRACT
Background: The ability to cope with concussion symptoms and manage stress is an important determinant of risk for prolonged symptoms. Objective: This open-label mixed-methods pilot study assessed the acceptability and credibility of a mindfulness-based intervention delivered through a digital therapeutic (DTx; therapeutic smartphone app) for pediatric concussion. Methods: Participants aged 12 to 18 years were recruited from an emergency department within 48â hours of a concussion (acute cohort) or from a tertiary care clinic at least 1-month post-concussion (persisting symptoms cohort). Participants completed a novel 4-week mindfulness-based intervention, for 10 to 15 minutes/day, at a minimum of 4 days/week. At 2 weeks, participants completed a credibility and expectancy questionnaire. At 4 weeks, participants completed questionnaires assessing satisfaction, usability and working alliance, as well as a semi-structured phone interview. Results: Ten participants completed the study outcomes (7 acute; 3 persisting symptoms). The intervention was perceived as credible (median/max possible = 6.50/9.00 [6.83,8.75]) and DTx was usable (median/max possible = 70.00/100.00 [55.00,82.50]). Participants rated their satisfaction with the DTx (median/max possible = 27.00/32.00 [24.50,29.50]) and the working alliance with the digital mindfulness guides (median/max possible = 3.92/5.00 [3.38-4.33]) as high. Four themes were identified from the qualitative data: (a) positive attributes; (b) negative attributes; (c) ideas for modifications; and (d) technical issues. Conclusion: Results show modifications to the DTx, instructions and mindfulness intervention, and potential ways to increase adherence by leveraging positive attributes. A randomized control trial will assess the effectiveness of the DTx MBI to decrease the risk of persisting symptoms and reduce the symptom burden following pediatric concussion.
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[This corrects the article DOI: 10.2196/49133.].
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Individual differences in mindfulness may impact quality of life after concussion. In a cross-sectional analysis, the moderating effect of mindfulness was tested on the association between symptom severity and quality of life in adults with persisting postconcussion symptoms (N = 85). Mindfulness and symptom severity were independently associated with quality of life; however, mindfulness did not moderate this association. "Nonreactivity" was independently associated with quality of life; however, it was not a significant moderator. Taking a nonreactive stance, or allowing experiences to come and go without effort to change them, may be relevant to quality-of-life outcomes after concussion.
Subject(s)
Mindfulness , Post-Concussion Syndrome , Quality of Life , Humans , Quality of Life/psychology , Cross-Sectional Studies , Male , Female , Adult , Post-Concussion Syndrome/psychology , Post-Concussion Syndrome/diagnosis , Young Adult , Brain Concussion/psychology , Brain Concussion/complications , Severity of Illness Index , Middle AgedABSTRACT
BACKGROUND: Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms. OBJECTIVE: The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group. METHODS: This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion. RESULTS: The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted. CONCLUSIONS: This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57226.
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BACKGROUND: Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates for such interventions are high. Evidence suggests that adults can develop therapeutic alliance with self-guided digital interventions, which is in turn associated with intervention engagement. However, no research has examined whether adolescents develop therapeutic alliance with self-guided digital interventions and what factors are important to its development. Additionally, social presence-the extent to which digital encounters feel like they are occurring in person-may be another relevant factor to understanding the nature of the connection between adolescents and a self-guided digital intervention, though this has yet to be explored. OBJECTIVE: This qualitative study explored the extent to which adolescents recovering from concussion developed therapeutic alliance and social presence during their use of a self-guided digital mindfulness-based intervention. Additionally, this study aimed to determine factors important to adolescents' development of therapeutic alliance and social presence with the intervention. METHODS: Adolescents aged between 12 and 17.99 years who sustained a concussion were recruited from 2 sites: a pediatric emergency department up to 48 hours after a concussion and a tertiary care clinic over 1 month following a concussion to capture adolescents who had both acute and persisting symptoms after concussion. Participants (N=10) completed a 4-week mindfulness-based intervention delivered through a smartphone app. Within the app, participants listened to audio recordings of mindfulness guides (voice actors) narrating psychoeducation and mindfulness practices. At 4 weeks, participants completed questionnaires and a semistructured interview exploring their experience of therapeutic alliance and social presence with the mindfulness guides in the intervention. RESULTS: Themes identified within the qualitative results revealed that participants developed therapeutic alliance and social presence by "developing a genuine connection" with their mindfulness guides and "sensing real people." Particularly important to the development of therapeutic alliance and social presence were the mindfulness guides' "personal backgrounds and voices," such that participants felt more connected to the guides by knowing information about them and through the guides' calm tone of voice in audio recordings. Quantitative findings supported qualitative results; participants' average score for therapeutic alliance was far above the scale midpoint, while the mixed results for social presence measures aligned with qualitative findings that participants felt that the mindfulness guides seemed real but not quite as real as an in-person connection would. CONCLUSIONS: Our data suggest that adolescents can develop therapeutic alliance and social presence when using digital interventions with no direct human contact. Adolescents' development of therapeutic alliance and social presence with self-guided digital interventions can be bolstered by increasing human-like qualities (eg, real voices) within interventions. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible treatment.
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The National Institutes of Health Toolbox-Cognition Battery (NIHTB-CB) is a tablet-based cognitive assessment intended for individuals with neurological diseases of all ages. NIHTB-CB practice effects (PEs), however, need clarification if this measure is used to track longitudinal change. We explored the test-retest PEs on NIHTB-CB performance at 3 months in young healthy adults (n = 22). We examined corrected T-scores normalized for demographic factors and calculated PEs using Cohen's d. There were significant PEs for all NIHTB-CB composite scores and on 4/7 subtests. This work suggests the need to further assess NIHTB-CB PEs as this may affect the interpretation of study results incorporating this battery.
Subject(s)
Cognition Disorders , Cognition , United States , Humans , Adult , Neuropsychological Tests , Reproducibility of Results , National Institutes of Health (U.S.)ABSTRACT
OBJECTIVES: To determine the association between early screen time (7-10 days postinjury) and postconcussion symptom severity in children and adolescents with concussion, as compared to those with orthopedic injury (OI). METHODS: This was a planned secondary analysis of a prospective longitudinal cohort study. Participants were 633 children and adolescents with acute concussion and 334 with OI aged 8 to 16, recruited from 5 Canadian pediatric emergency departments. Postconcussion symptoms were measured using the Health and Behavior Inventory at 7 to 10 days, weekly for 3 months, and biweekly from 3 to 6 months postinjury. Screen time was measured by using the Healthy Lifestyle Behavior Questionnaire. Generalized least squares models were fit for 4 Health and Behavior Inventory outcomes (self- and parent-reported cognitive and somatic symptoms), with predictors including screen time, covariates associated with concussion recovery, and 2 3-way interactions (self- and parent-reported screen time with group and time postinjury). RESULTS: Screen time was a significant but nonlinear moderator of group differences in postconcussion symptom severity for parent-reported somatic (P = .01) and self-reported cognitive symptoms (P = .03). Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the OI group during the first 30 days postinjury but not after 30 days. Other risk factors and health behaviors had stronger associations with symptom severity than screen time. CONCLUSIONS: The association of early screen time with postconcussion symptoms is not linear. Recommending moderation in screen time may be the best approach to clinical management.
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Athletic Injuries , Brain Concussion , Post-Concussion Syndrome , Child , Adolescent , Humans , Prospective Studies , Screen Time , Longitudinal Studies , Canada/epidemiology , Brain Concussion/complications , Brain Concussion/diagnosis , Post-Concussion Syndrome/diagnosis , Post-Concussion Syndrome/etiology , Athletic Injuries/complicationsABSTRACT
OBJECTIVES: There is a growing demand for remote assessment options for measuring cognition after mild traumatic brain injury (mTBI). The current study evaluated the criterion validity of the Brief Test of Adult Cognition by Telephone (BTACT) in distinguishing between adults with mTBI and trauma controls (TC) who sustained injuries not involving the head or neck. METHODS: The BTACT was administered to the mTBI (n = 46) and TC (n = 35) groups at 1-2 weeks post-injury. Participants also completed the Rivermead Post Concussion Symptoms Questionnaire. RESULTS: The BTACT global composite score did not significantly differ between the groups (t(79) = -1.04, p = 0.30); the effect size was small (d = 0.23). In receiver operating characteristic curve analyses, the BTACT demonstrated poor accuracy in differentiating between the groups (AUC = 0.567, SE = 0.065, 95% CI [0.44, 0.69]). The BTACT's ability to discriminate between mTBI and TCs did not improve after excluding mTBI participants (n = 15) who denied ongoing cognitive symptoms (AUC = 0.567, SE = 0.072, 95% CI [0.43, 0.71]). CONCLUSIONS: The BTACT may lack sensitivity to subacute cognitive impairment attributable to mTBI (i.e., not explained by bodily pain, post-traumatic stress, and other nonspecific effects of injury).
Subject(s)
Brain Concussion , Cognitive Dysfunction , Adult , Humans , Brain Concussion/complications , Brain Concussion/diagnosis , Brain Concussion/psychology , Neuropsychological Tests , Cognition , Cognitive Dysfunction/diagnosis , Cognitive Dysfunction/etiology , Longitudinal StudiesABSTRACT
Adolescents with persisting post-concussive symptoms often report high levels of emotional distress, which can impact their daily functioning. The associations between modifiable factors, such as perceptions of recovery, and emotional distress have not been investigated in this age group. OBJECTIVE: To evaluate perceptions about recovery duration (e.g., "my symptoms will last a long time", "my symptoms will be permanent rather than temporary") and its associations with emotional distress and functioning in children and adolescents with a slower post-concussive recovery. METHODS: Participants (N = 49, 69% girls, 11-17 years old, M = 15.8 years old, SD = 1.8) were recruited from a concussion clinic on average 7.7 months after injury (SD = 2.5). Measures included the Illness Perception Questionnaire Revised (perceived duration of symptoms only) to evaluate recovery expectations, the Health and Behavior Inventory (self and parent reports) to evaluate current post-concussive symptoms (cognitive and somatic symptoms), the emotional distress subscale of the Strengths and Difficulties Questionnaire (SDQ-self-report), and the emotional functioning subscale of the Pediatric Quality of Life Questionnaire (PedsQL-self-report). RESULTS: Regression analyses (linear models with all covariates entered at once) suggested that greater expectations for symptom persistence were significantly associated with higher emotional distress on both SDQ and PedsQL subscales, after controlling for post-concussive symptom severity and other confounds. Emotional distress/functioning was not associated with perceptions of symptom duration reported by parents, severity of post-concussive symptoms (self- and parent reports), age, number of concussions, time since injury, or a history of mental health concern or diagnosis (parent-reported). CONCLUSIONS: This study suggests that pessimistic attitudes for recovery duration may be more strongly associated with emotional distress than current post-concussive symptom severity or a history of mental health concern or diagnosis.
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Psychological Distress , Adolescent , Brain Concussion/psychology , Child , Emotions , Female , Humans , Male , Post-Concussion Syndrome/diagnosis , Post-Concussion Syndrome/psychology , Quality of LifeABSTRACT
Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Brain Concussion/complications , Brain Concussion/therapy , Headache , HumansABSTRACT
OBJECTIVE: To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could affect selective change on targeted coping outcomes. DESIGN: Randomized controlled trial. SETTING: Outpatient concussion clinics. PARTICIPANTS: Adults (N=73, mean age=42.5y) who had persistent postconcussion symptoms and high avoidance or endurance behavior were enrolled at a mean of 12.9 weeks post injury. Ten participants did not complete treatment. INTERVENTIONS: Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy [GET]) or endurance coping (operant condition-based pacing strategies plus mindfulness training [Pacing+]). MAIN OUTCOME MEASURES: Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire. RESULTS: Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275 of 618). A total of 65.8% (73 of 111) of eligible patients were randomized (37 to GET, 36 to Pacing+), meeting accrual targets; 91.7% (55 of 60) of participants perceived treatment as credible. Therapists covered a mean of 96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47 of 66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater posttreatment reductions in avoidance behavior compared with Pacing+ (Cohen's drepeated measures, 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's drepeated measures, 0.39). CONCLUSIONS: These findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Adaptation, Psychological , Adult , Brain Concussion/rehabilitation , Feasibility Studies , Humans , Post-Concussion Syndrome/psychology , Surveys and QuestionnairesABSTRACT
OBJECTIVE: The avoidance-endurance model (AEM) proposes multiple pathways from acute to chronic pain, with distinct cognitive and behavioral components in each pathway. The AEM may also be applicable to persistent symptoms after concussion. In this study, we tested the AEM as an explanatory framework for concussion outcomes, by using mediation analyses through the proposed psychological mechanisms. Based on the AEM, we hypothesized that postconcussion symptoms would significantly predict avoidance behavior through catastrophizing, and endurance behavior through thought suppression and self-distraction. PARTICIPANTS AND METHODS: We recruited 84 adults seeking treatment at 2 outpatient concussion clinics (M = 41.8 years old, 63% female) who completed measures of postconcussion symptoms, catastrophizing, thought suppression, "self-distraction" (Five Factor Mindfulness Questionnaire "Act with Awareness" Scale reverse-scored), avoidance behavior, and endurance behavior at an average of 17.8 weeks postconcussion. We conducted 3 mediation analyses to assess each of the AEM pathways. RESULTS: We found a significant indirect effect of postconcussion symptoms on avoidance behavior through catastrophizing (ab = .113 (.036), 95% CI [.053, .195]). The indirect effects of postconcussion symptoms on endurance behavior through thought suppression (ab = .011 (.012), 90% CI [.002, .035]) and "self-distraction" (ab = .003 (.009), 90% CI [.008, .022]) were not statistically significant. CONCLUSIONS: Results supported the catastrophizing-avoidance pathway in concussion, but not the thought-suppression-endurance or self-distraction-endurance pathways. Therefore, catastrophic thinking about concussion symptoms may be an appropriate treatment target for individuals who exhibit fear-avoidance behavior. Further research is needed to establish whether thought suppression and self-distraction are relevant for interventions aimed at reducing excessive endurance behavior. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Adult , Avoidance Learning , Brain Concussion/complications , Catastrophization , Fear , Female , Humans , MaleABSTRACT
The objective of the current study was to develop a measure of fear avoidance behavior after concussion for youth and parent respondents and examine its basic psychometric properties and correlates. Children (N = 51) who were seen in a hospital concussion clinic after sustaining a concussion (M = 7.6 months, SD = 7.01) and their primary caregiver (N = 51)completed self- and informant-report measures of fear avoidance (Pediatric Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire; PFAB-TBI), post-concussion symptoms (Health Behavior Inventory), emotional distress (Strengths and Difficulties Questionnaire), and quality of life (Pediatric Quality of Life Inventory Version 4.0). The self- and informant-report PFAB-TBI scores were moderately correlated (r = 0.51, p < 0.001). Neither measure demonstrated floor or ceiling effects. Both had strong internal consistency (Cronbach's α = 0.87 and 0.89, respectively). The PFAB-TBI self-report was positively correlated with somatic symptoms (r = 0.37), emotional distress (r = 0.39), and negatively associated with quality of life (r = -0.57). The PFAB-TBI informant-report was positively associated with informant reported somatic symptoms (r = 0.52) and emotional distress (r = .50) Overall, the PFAB-TBI has desirable basic measurement properties and expected correlations with clinical outcomes. This measure can potentially help clinicians and researchers better understand the impacts of fear avoidance behavior after pediatric concussion.
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Adolescent , Avoidance Learning , Brain Concussion/diagnosis , Child , Fear , Humans , Quality of Life , Surveys and QuestionnairesABSTRACT
OBJECTIVE: Fear avoidance behavior after a concussion or mild traumatic brain injury (mTBI) is associated with a number of adverse outcomes, such as higher symptom burden, emotional distress, and disability. The Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) is a recently developed and validated self-report measure of fear avoidance after mTBI. The objective of this study was to derive clinical normative data for the FAB-TBI. To determine whether demographic stratification was necessary and to further support clinical interpretation, we also explored associations between fear avoidance behavior and demographic and injury variables. SETTING: Five concussion clinics in Canada. PARTICIPANTS: Adults who sustained an mTBI (N = 563). DESIGN: Cross-sectional. MAIN MEASURES: Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) and measures of postconcussion symptom burden (Rivermead Postconcussion Symptoms Questionnaire, Sport Concussion Assessment Tool-5) at clinic intake. RESULTS: Generalized linear modeling revealed that females reported more fear avoidance than males (95% CI = 0.66 to 2.75), indicating that FAB-TBI normative data should be stratified by sex. Differences between recruitment sites on FAB-TBI scores were reduced but not eliminated by controlling for potential confounds. Loss of consciousness (95% CI =0.61 to 2.76) and higher postconcussion symptom burden (95% CI = 0.79 to 1.03) were also associated with higher FAB-TBI scores, but time since injury was not (95% = CI -0.4 to 0.03). Tables to convert FAB-TBI raw scores to Rasch scores to percentiles are presented. CONCLUSION: These findings support clinical interpretation of the FAB-TBI and further study of fear avoidance after mTBI.
Subject(s)
Brain Concussion , Brain Injuries, Traumatic , Post-Concussion Syndrome , Adult , Avoidance Learning , Brain Concussion/diagnosis , Cross-Sectional Studies , Fear , Female , Humans , Male , Surveys and QuestionnairesABSTRACT
BACKGROUND: Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders. METHOD: The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis. RESULTS: CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes. LIMITATIONS AND CONCLUSIONS: This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.
Subject(s)
Behavior Therapy , Medication Adherence , Chronic Disease , Exercise , Humans , Randomized Controlled Trials as TopicABSTRACT
Objective: Fear-avoidance and endurance behavior are well-established maladaptive coping styles in several chronic health conditions. There is also emerging evidence that both fear-avoidance and endurance coping are associated with poor outcome from mild traumatic brain injury (mTBI). The current study sought to characterize the early trajectories of avoidance and endurance behavior and confirm their association with disability outcomes. Method: Adults with mTBI (N = 88) completed measures of avoidance, endurance, and postconcussive symptoms at clinic intake (M = 40.2 days since injury). Avoidance and endurance measures were readministered 1 month later (N = 79), and a measure of perceived functional disability (World Health Organization Disability Assessment Schedule 2.0) was completed 3 months after clinic intake (N = 69). Results: Avoidance and endurance coping were weakly positively correlated with each other at intake (r = .28) and at 1 month postintake (r = .28). Change scores on these two measures over time were not significantly correlated (r = .04). Avoidance coping tended to decrease over time (95% CI [0.6, 2.5]; p = .002), whereas changes in endurance coping were variable. In generalized linear modeling, higher avoidance and endurance at clinic intake and increasing (or less rapidly decreasing) levels of these coping styles over 1 month was associated with greater perceived disability ratings at 3 months, even after controlling for postconcussion symptom severity at intake. Conclusion: These findings suggest that avoidance and endurance behavior are distinct coping styles with unique trajectories during the subacute recovery period. The results also support the need for psychologically informed early interventions that target specific profiles of maladaptive coping to mitigate risk for poor outcomes post-mTBI. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Subject(s)
Brain Concussion , Post-Concussion Syndrome , Adaptation, Psychological , Adult , Brain Concussion/complications , Fear , Humans , Surveys and QuestionnairesABSTRACT
OBJECTIVE: Somatization is thought to underlie functional somatic syndromes (FSSs) and may also contribute to prolonged symptoms after mild traumatic brain injury (mTBI). The investigators evaluated the prevalence of FSSs in patients seeking specialty care after mTBI and whether a history of FSSs was associated with symptom persistence. METHODS: A total of 142 patients with mTBI completed questionnaires regarding demographic information, injury characteristics, and medical history, including history of diagnosed FSSs at clinic intake (mean=41 days postinjury [SD=22.41]). Postconcussion symptoms were assessed at clinic intake and again 1 and 3 months later. A linear mixed-effects model was used to determine whether history of FSSs was related to persistent mTBI symptoms over time. RESULTS: A history of at least one FSS was reported by 20.4% of patients. In the linear mixed model, postconcussion symptom scores were not significantly different over time among patients with a history of one or more FSSs or two or more FSSs from those with no FSSs. A history of one or more FSSs or two or more FSSs (versus no FSS) was not associated with increased odds of severe postconcussion symptoms at clinic intake (one or more FSSs: odds ratio=0.88, 95% CI=0.38-2.03; two or more FSSs: odds ratio=1.78, 95% CI=0.45-7.03), at the 1-month follow-up visit (one or more FSSs: odds ratio=0.57, 95% CI=0.22-1.45; two or more FSSs: odds ratio=0.57, 95% CI=0.14-2.37), or at the 3-month follow-up visit (one or more FSSs: odds ratio=0.97, 95% CI=0.36-2.63; two or more FSSs: odds ratio=1.27, 95% CI=0.29-5.65). CONCLUSIONS: In this sample, the prevalence rates of FSSs were higher than rates previously reported for the general population. However, FSS history did not predict higher postconcussion symptom burden at clinic intake or persistence over the following 3 months. Further research is needed to clarify the potential role of somatization in poor mTBI outcome.
Subject(s)
Brain Concussion/complications , Post-Concussion Syndrome/epidemiology , Somatoform Disorders/epidemiology , Adult , Female , Humans , Male , Prevalence , Surveys and QuestionnairesABSTRACT
OBJECTIVE: To evaluate an abbreviated NIH Toolbox Cognition Battery (NIHTB-CB) protocol that can be administered remotely without any in-person assessments, and explore the agreement between prorated scores from the abbreviated protocol and standard scores from the full protocol. METHODS: Participant-level age-corrected NIHTB-CB data were extracted from six studies in individuals with a history of stroke, mild traumatic brain injury (mTBI), treatment-resistant psychosis, and healthy controls, with testing administered under standard conditions. Prorated fluid and total cognition scores were estimated using regression equations that excluded the three fluid cognition NIHTB-CB instruments which cannot be administered remotely. Paired t tests and intraclass correlations (ICCs) were used to compare the standard and prorated scores. RESULTS: Data were available for 245 participants. For fluid cognition, overall prorated scores were higher than standard scores (mean difference = +4.5, SD = 14.3; p < 0.001; ICC = 0.86). For total cognition, overall prorated scores were higher than standard scores (mean difference = +2.7, SD = 8.3; p < 0.001; ICC = 0.88). These differences were significant in the stroke and mTBI groups, but not in the healthy control or psychosis groups. CONCLUSIONS: Prorated scores from an abbreviated NIHTB-CB protocol are not a valid replacement for the scores from the standard protocol. Alternative approaches to administering the full protocol, or corrections to scoring of the abbreviated protocol, require further study and validation.
Subject(s)
Brain Injuries, Traumatic/psychology , Cognition Disorders/diagnosis , Cognition/physiology , National Institutes of Health (U.S.) , Neuropsychological Tests/standards , Adult , Female , Humans , Male , Middle Aged , Psychometrics , Reproducibility of Results , Sensitivity and Specificity , United States , Young AdultABSTRACT
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.