Use of Virtual Care Strategies to Join Multidisciplinary Teams Evaluating Work-Related Injuries in Rural Residents.

Background: Rural injured workers requiring multidisciplinary assessments for musculoskeletal disorders face health access disparities, which include travel to urban centers. Virtual care can enhance access to multidisciplinary team care for musculoskeletal conditions in rural areas. Materials and Methods: A retrospective chart audit of 136 multidisciplinary assessment reports of injured workers was conducted. Comprehensive management recommendations from the health care assessment team were extracted for analysis. The health care team used virtual technologies to join with patients and at least one local rural health practitioner in one of three locations. Remote presence robotics (RPR; Xpress Technology™) or laptop-based telehealth was used to complete the assessments. Results: RPR were used in 46% of assessments over two sites, with 54% using laptop-based telehealth at a third site. Frequencies of team members' assessment using technologies were as follows: physical therapist (100%), psychologist (78%), plastic surgeon (8%), and physician (43%). Spine (42%) and shoulder (32%) disorders were the most common problems. Most workers (79%) were 3 or more months postinjury. The most common management recommendation was the need for daily comprehensive rehabilitation care (76%). Travel time was saved by 89% of participants. Conclusions: Virtual care was used to unite multidisciplinary assessment teams for the evaluation of injured rural workers with complex musculoskeletal injuries. Future research recommendations include comparing between virtual and fully in-person multidisciplinary assessment and recommendation findings, and evaluation of patient and practitioner experiences with comprehensive virtual team assessments.

Why exercise may be beneficial in concussion rehabilitation: A cellular perspective.

INTRODUCTION: Concussion diagnosis and rehabilitation management has become a prevalent area of research, and yet much is still unknown about these complex injuries. Historically, exercise prescription post-concussion was conservatively used for rehabilitation due to the suspected harmful effects that exercise can have on damaged neurons, and increase in symptoms. However, there has been a shift to implement exercise earlier into recovery as several studies have demonstrated positive outcomes. OBJECTIVE: The objective of this literature review is to update the reader about new advances in concussion research related to the beneficial effects of physical activity from both a neurometabolic and a broader physiological perspective, using gene expression as a vehicle to demonstrate why and how physical activity has the capacity to optimize recovery from a cellular perspective. To further this clinical guideline, the evidence must continue to support these positive outcomes from an inductive and deductive physiologic approach (i.e., the clinical evidence aligned from a micro- to macroscopic approach and vice versa). DESIGN: Narrative review. METHODS: Pubmed and Medline were used with the following key words: concussion and, physical activity, neurometabolic, gene regulation, trauma, nervous system, mild head injury, acute exercise, cellular physiology and pathophysiology. CONCLUSION: It is our contention that understanding the cellular perspective will help guide clinical management, and promote research into post-concussion exercise.

An Evidence-Based Objective Study Protocol for Evaluating Cardiovascular and Cerebrovascular Indices Following Concussion: The Neary Protocol.

INTRODUCTION: The prevalence and incidence of sport-related concussion have continued to increase over the past decade, and researchers from various backgrounds strive for evidenced-based clinical assessment and management. When diagnosing and managing a concussion, a battery of tests from several domains (e.g., symptom reporting, neurocognitive, physiology) must be used. In this study, we propose and develop an objective, evidence-based protocol to assess the pathophysiology of the brain by using non-invasive methods. METHODS: Contact sport athletes (n = 300) will be assessed at the beginning of the season in a healthy state to establish baseline values, and then prospectively followed if a mild traumatic brain injury (mTBI) occurs on approximately days 1-2, 3-5, 7-10, 21, 30, and subsequently thereafter, depending on the severity of injury. The protocol includes spontaneous measurements at rest, during head postural change, controlled breathing maneuvers for cerebrovascular reactivity, a neurovascular coupling stimuli, and a baroreflex/autoregulation maneuver. Physiological data collection will include cerebral blood flow velocity, cerebral oxygenation, respiratory gases for end-tidal oxygen and carbon dioxide, finger photoplethysmography for blood pressure, seismocardiography for cardiac mechanics, and electrocardiography. Conclusion, Limitations, and Ethics: The protocol will provide an objective, physiological evidence-based approach in an attempt to better diagnose concussion to aid in return-to-play or -learn. Ethics approval has been granted by the University Research Ethics Board.

A retrospective analysis of postrehabilitation outcomes following total knee arthroplasty.

BACKGROUND AND PURPOSE: Total knee arthroplasty (TKA) is one of the most frequently performed orthopaedic procedures in Canada. Despite the frequency at which TKAs are performed, few studies have examined the association between postoperative outcomes and long-term functional outcomes following group-based rehabilitation in Canada. The primary objective of the present study was to examine changes in flexion and extension from intake to discharge from rehabilitation in patients in Saskatchewan, Canada. A secondary objective was to explore the demographic and medical predictors of range of motion in TKA patients, and treatment duration. METHODS: A retrospective chart review from an outpatient rehabilitation clinical database was conducted between September 2014 and December 2016, and assessed demographic and medical variables. RESULTS: A total of 672 patient charts were included in the study. Significant improvements (p < 0.001) were noted from intake to discharge from rehabilitation for flexion and extension. Right-side TKA, flexion at intake and the length of treatment predicted flexion at discharge from rehabilitation (R2  = 0.23). Gender, right side TKA, extension at intake and the length of treatment predicted extension at discharge from rehabilitation (R2  = 0.23). Lastly, age, flexion at intake and extension at intake predicted length of treatment in the rehabilitation programme (R2  = 0.21). CONCLUSIONS: Patients who participated in rehabilitation following TKA experienced improvements in flexion and extension. Those with decreased flexion and extension after TKA may be less likely to experience a desirable range of motion, indicating a need for more intensive targeted rehabilitation in this group, and adjustments in hospital and community care.

Heart rate variability and implication for sport concussion.

Finding sensitive and specific markers for sports-related concussion is both challenging and clinically important. Such biomarkers might be helpful in the management of patients with concussion (i.e. diagnosis, monitoring and risk prediction). Among many parameters, blood flow-pressure metrics and heart rate variability (HRV) have been used to gauge concussion outcomes. Reports on the relation between HRV and both acute and prolonged concussion recovery are conflicting. While some authors report on differences in the low-frequency (LF) component of HRV during postural manipulations and postexercise conditions, others observe no significant differences in various HRV measures. Despite the early success of using the HRV LF for concussion recovery, the interpretation of the LF is debated. Recent research suggests the LF power is a net effect of several intrinsic modulatory factors from both sympathetic and parasympathetic branches of the autonomic nervous system, vagally mediated baroreflex and even some respiratory influences at lower respiratory rate. There are only a few well-controlled concussion studies that specifically examine the contribution of the autonomic nervous system branches with HRV for concussion management. This study reviews the most recent HRV- concussion literature and the underlying HRV physiology. It also highlights cerebral blood flow studies related to concussion and the importance of multimodal assessment of various biological signals. It is hoped that a better understanding of the physiology behind HRV might generate cost-effective, repeatable and reliable protocols, all of which will improve the interpretation of HRV throughout concussion recovery.

Assessing prefrontal cortex oxygenation after sport concussion with near-infrared spectroscopy.

BACKGROUND: Clinicians typically rely on neuropsychological and balance tests to track concussion recovery. The aforementioned tests imply impairments that are based on performance, but these tests do not directly measure brain physiology throughout concussion recovery. Because of these issues, an objective biomarker that can index severity and the recovery timeline is needed. Moreover, the number of concussions occurring at a recreational level requires the biomarker to be easily administered in a cost effective manner, and the results easily interpreted. METHODS: To address these issues, near-infrared spectroscopy was used to assess the relative changes in oxy (HbO2 )- and deoxyhaemoglobin and the associated standard deviations (SD) in the prefrontal cortex. Resting haemoglobin, and haemoglobin changes in response to hypercapnia (five repeated 20s breath holds), was measured in all participants. Data were aggregated into healthy baselines (n = 115), and concussed participants on days 1-3 (n = 14), 4-6 (n = 8), and 7-14 (n = 11). The data were statistically compared using a 1 × 4 ANOVA. RESULTS: Resting HbO2 values progressively lowered from days 1-3 to 7-14 (with no differences compared to controls). The second major finding showed that hypercapnic HbO2 SD was significantly lower than resting values on days 1-3 and 4-6, but reversed back towards the healthy control group on day 7-14. CONCLUSION: Monitoring cerebral oxygenation changes is a viable biomarker to assess the physiological state of the brain following concussion.

Parasympathetic baroreflexes and heart rate variability during acute stage of sport concussion recovery.

PRIMARY OBJECTIVE: To assess and compare the parasympathetic state of individuals in healthy vs concussion groups, by measuring cardiovascular metrics under resting and baroreflex conditions using a squat-stand manoeuvre. RESEARCH DESIGN: This was a retrospective mixed-method study, with participants who sustained a medically diagnosed sport concussion (n = 12), being tested within 72-hours post-injury. METHODS AND PROCEDURES: Participant's heart rate (Electrocardiogram, ECG) and blood pressure (finger plethysmography) data was collected during rest and during 10-second squat-stands (10SS, 0.05 Hz). Blood pressure and heart rate standard deviation data was analysed in the 0-5 seconds and 6-10 seconds periods of squatting and standing. Resting and baroreflex ECG data were analysed via Fourier Transformations for %Low Frequency and %High Frequency (%LF and %HF). RESULTS: The control group alleviated more pressure and had a significantly higher standard deviation of heart rate during the 6-10 seconds of squatting (p < 0.05). Overall heart rate standard deviation in the concussion group was significantly lower than healthy controls when standing (p < 0.05). There were no differences in %LF and % HF between groups or between rest and 10SS. CONCLUSION: This study provides preliminary evidence that autonomic function is dysregulated following mTBI within the initial 72 hours of injury.

A randomized controlled trial of mindfulness-based stress reduction to manage affective symptoms and improve quality of life in gay men living with HIV.

UNLABELLED: To determine whether MBSR groups would help gay men living with HIV improve psychosocial functioning and increase mindfulness compared to treatment-as-usual (TAU). METHODS: 117 participants were randomized 2:1 to MBSR or TAU. No new psychosocial or psychopharmacological interventions were initiated within 2 months of baseline. Standardized questionnaires were administered pre-, postintervention and at 6 months. An intent-to-treat analysis found significant benefits of MBSR: at post-intervention and 6 months follow up, MBSR participants had significantly lower avoidance in IES and higher positive affect compared to controls. MBSR participants developed more mindfulness as measured by the Toronto Mindfulness Scale (TMS) including both TMS subscales, curiosity and decentering, at 8-week and 6 months. For the sample as a whole, increase in mindfulness was significantly correlated with reduction in avoidance, higher positive affect and improvement in depression at 6 months. MBSR has specific and clinically meaningful effects in this population.

The Toronto Mindfulness Scale: development and validation.

In this study, the authors both developed and validated a self-report mindfulness measure, the Toronto Mindfulness Scale (TMS). In Study 1, participants were individuals with and without meditation experience. Results showed good internal consistency and two factors, Curiosity and Decentering. Most of the expected relationships with other constructs were as expected. The TMS scores increased with increasing mindfulness meditation experience. In Study 2, criterion and incremental validity of the TMS were investigated on a group of individuals participating in 8-week mindfulness-based stress reduction programs. Results showed that TMS scores increased following treatment, and Decentering scores predicted improvements in clinical outcome. Thus, the TMS is a promising measure of the mindfulness state with good psychometric properties and predictive of treatment outcome.

(Dis)embodying gender and sexuality in testicular cancer.

Testicular cancer is the most common cancer in men aged 15-34. Although post-treatment prognosis is generally very good, the impact on sexuality, gender identity and fertility is amplified in this age group. A Canadian study of men with testicular cancer explores how men (re)consider questions of sexuality and gender post diagnosis and treatment. Semi-structured interviews with 40 men were analyzed using thematic decomposition, an analytic technique that combines discursive approaches with thematic analysis. The theoretical framework that guides this work relies on material discursive approaches. From an analytic stance, this perspective is concerned with a focus on the ways in which both subjectivity and the body are experienced and constituted in language. In particular, we are concerned with how these men interpret the (altered) male body as a locus of gender signification and gender disruption. Men in this study construct testicular cancer as alternately inhibiting and enhancing masculinity and sexuality. Disruption interpolates with potentiality. A discourse of precarious masculinity predominates these accounts, wherein the link between anatomy and masculinity is simultaneously asserted and disavowed. Constructions of anatomical essentialism (i.e., testicular integrity is equated with masculinity) are juxtaposed against construals of anatomical superfluousness (i.e., other sites of sexuality and male identity are emphasized as being more central).

Coping, catastrophizing and chronic pain in breast cancer.

This cross-sectional study investigated the relationships between individual differences in coping and catastrophizing, and markers of adaptation to chronic pain associated with breast cancer. Sixty-eight breast cancer patients with chronic pain due to either cancer or cancer-treatment were administered self-report instruments that assess active and passive coping, catastrophizing, pain, disability, and mood disturbance. Regression analyses were performed to investigate the unique contribution of differences in coping and catastrophizing to the various markers of adaptation. Both active and passive coping explained unique variance in self-reported disability; active coping was associated with less disability while passive coping was associated with greater disability. Catastrophizing explained unique variance in anxiety and depression scores; higher levels of catastrophizing were associated with greater emotional distress. The results suggest that coping and catastrophizing may contribute to different outcomes in chronic pain in breast cancer patients and provides preliminary evidence that they may be important targets of psychological treatments.

What do we really know about mindfulness-based stress reduction?

OBJECTIVE: Mindfulness-Based Stress Reduction (MBSR) is a clinical program, developed to facilitate adaptation to medical illness, which provides systematic training in mindfulness meditation as a self-regulatory approach to stress reduction and emotion management. There has been widespread and growing use of this approach within medical settings in the last 20 years, and many claims have been made regarding its efficacy. This article will provide a critical evaluation of the available state of knowledge regarding MBSR and suggestions for future research. METHODS: A review of the current literature available within the medical and social sciences was undertaken to provide an evaluation regarding what we know about the construct of mindfulness, the effectiveness of MBSR, and mechanisms of action. RESULTS: There has been a paucity of research and what has been published has been rife with methodological problems. At present, we know very little about the effectiveness of this approach. However, there is some evidence that suggests that it may hold some promise. CONCLUSIONS: The available evidence does not support a strong endorsement of this approach at present. However, serious investigation is warranted and strongly recommended.