Graded Exposure Therapy for Fear Avoidance Behaviour After Concussion (GET FAB): protocol for a multisite Canadian randomised controlled trial.

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.

Relationships between vestibular issues, noise sensitivity, anxiety and prolonged recovery from mild traumatic brain injury among adults: a scoping review.

BACKGROUND: We investigated the extent of literature and findings on relationships between vestibular issues, noise sensitivity (NS), and anxiety. We were interested in how relationships among these factors impacted adults' recovery three months or more after mild traumatic brain injury (mTBI). METHODS: We conducted a scoping review to evaluate the extent of evidence linking relationships between vestibular issues, NS and anxiety with recovery after mTBI. Data relating to study characteristics and key findings were extracted and used to inform a critical narrative synthesis of findings. RESULTS: After screening and full-text review, we included two studies. Both studies considered the combination of vestibular issues, NS and anxiety and mTBI recovery. Vestibular issues, NS and anxiety were all significantly associated with one another and their presence was the strongest indicator that symptoms would extend beyond three-months after mTBI. CONCLUSION: Few studies have focused on the relationships that vestibular issues, NS and anxiety have with one another and recovery after mTBI. Given the apparent strong relationships between these factors and prolonged recovery, we highlight this as an area warranting further investigation.

Vestibular issues, noise sensitivity and anxiety all appear to impact on recovery from mild traumatic brain injury.There appear to be quite strong relationships between vestibular, noise sensitivity and anxiety symptoms following mild traumatic brain injury.More work exploring these key symptoms and how they impact recovery from mild traumatic brain injury using a wide range of study methods and approaches are needed to advance the field.

Valued living after mild traumatic brain injury: Characteristics and relationship with outcomes.

Psychological factors are strong predictors of mild traumatic brain injury (mTBI) recovery, consequently, psychological interventions can form part of an individual's rehabilitation. This may include enhancing valued living (VL), an approach that is effective in severe and mixed acquired brain injury samples. This study aimed to characterize VL in mTBI and explore its relationship with mTBI and mental health outcomes. 56 participants with a mTBI completed self-report measures before engaging in a psychological intervention. Pre-injury mental health and other demographic and injury-related variables, VL, post-concussion symptoms (PCS), functional disability, and stress, anxiety and depression were measured. A pre-injury mental health condition was significantly associated with VL. VL was uniquely associated with depression after mTBI (ß = -0.08, p = .05), however, there was no relationship with PCS, functional disability, stress or anxiety (p > .05). Following mTBI individuals with a pre-injury mental health condition or who experience heightened depressive symptoms may benefit from a values-based intervention as part of their rehabilitation. Future research, however, is needed to examine the role of VL in mTBI recovery.

Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment.

Introduction: Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management. Methods: Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach. Results: From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%. Conclusion: Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.

Network analysis applied to post-concussion symptoms in two mild traumatic brain injury samples.

Objective: A latent disease explanation cannot exclusively explain post-concussion symptoms after mild traumatic brain injury (mTBI). Network analysis offers an alternative form of explanation for relationships between symptoms. The study aimed to apply network analysis to post-concussion symptoms in two different mTBI cohorts; an acute treatment-seeking sample and a sample 10 years post-mTBI. Method: The treatment-seeking sample (n = 258) were on average 6 weeks post-injury; the 10 year post mTBI sample (n = 193) was derived from a population-based incidence and outcomes study (BIONIC). Network analysis was completed on post-concussion symptoms measured using the Rivermead Post-Concussion Questionnaire. Results: In the treatment-seeking sample, frustration, blurred vision, and concentration difficulties were central to the network. These symptoms remained central in the 10 year post mTBI sample. A Network Comparison Test revealed evidence of a difference in network structure across the two samples (p = 0.045). However, the only symptoms that showed significant differences in strength centrality across samples were irritability and restlessness. Conclusion: The current findings suggest that frustration, blurred vision and concentration difficulties may have an influential role in the experience and maintenance of post-concussion symptoms. The impact of these symptoms may remain stable over time. Targeting and prioritising the management of these symptoms may be beneficial for mTBI rehabilitation.

Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis.

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

Patterns of post-traumatic stress symptoms in mild traumatic brain injury and their relationship with outcomes: a latent profile analysis.

INTRODUCTION: Post-traumatic stress symptoms (PTSS) are known to contribute to postconcussion symptoms and functional status following mild traumatic brain injury (mTBI). Identifying symptom cluster profiles provide an opportunity to better understand PTSS and their influence on these outcomes. In this study, latent profiles of PTSS following mTBI were identified, and their association with mTBI outcomes was examined. The predictive role of demographic and injury related variables on profile membership was also explored. METHOD: Adults (N = 252) completed self report measures of PTSS and mTBI outcomes (post-concussion symptoms and functional status) within three months of mTBI. These measures were re-administered six months later (N = 187). Latent profile analysis (LPA) was used to ascertain the latent class structure of PTSS, and regression analysis to examine predictors of profiles. ANCOVA, with general psychological distress as a covariate, revealed the relationship between profiles and mTBI outcomes. RESULTS: LPA identified a four-profile model to best describe PTSS at baseline. This included a resilient (49.6%), moderate (30.6%), moderate with high intrusion/avoidance (14.3%) and a highly symptomatic profile (5.6%). A secondary school education or less and/or unemployment before mTBI was significantly more likely in the highly symptomatic profile, as well as sustaining an mTBI due to an assault or motor vehicle accident. PTSS latent class membership was significantly associated with mTBI outcomes even when controlling for general psychological distress. The resilient group had significantly better outcomes at baseline and six-month follow-up. However, no significant differences in mTBI outcomes emerged between the moderate, moderate with high intrusion/avoidance and the highly symptomatic profiles. CONCLUSION: The current study provides novel information on the symptom profiles of PTSS in mTBI, predictors of profile membership and their relationship with mTBI outcomes. Although future research using this approach is needed, the current study offers a more in-depth understanding of PTSS in mTBI to inform clinical care.

A Framework for Understanding the Contribution of Psychosocial Factors in Biopsychosocial Explanatory Models of Persistent Postconcussion Symptoms.

Biopsychosocial models are currently used to explain the development of persistent postconcussion symptoms (PPCS) following concussion. These models support a holistic multidisciplinary management of postconcussion symptoms. One catalyst for the development of these models is the consistently strong evidence pertaining to the role of psychological factors in the development of PPCS. However, when applying biopsychosocial models in clinical practice, understanding and addressing the influence of psychological factors in PPCS can be challenging for clinicians. Accordingly, the objective of this article is to support clinicians in this process. In this Perspective article, we discuss current understandings of the main psychological factors involved in PPCS in adults and summarize these into 5 interrelated tenets: preinjury psychosocial vulnerabilities, psychological distress following concussion, environment and contextual factors, transdiagnostic processes, and the role of learning principles. With these tenets in mind, an explanation of how PPCS develop in one person but not in another is proposed. The application of these tenets in clinical practice is then outlined. Guidance is provided on how these tenets can be used to identify psychosocial risk factors, derive predictions, and mitigate the development of PPCS after concussion from a psychological perspective within biopsychosocial conceptualizations. IMPACT: This Perspective helps clinicians apply biopsychosocial explanatory models to the clinical management of concussion, providing summary tenets that can guide hypothesis testing, assessment, and treatment.

Fear avoidance and return to work after mild traumatic brain injury.

OBJECTIVES: Fear avoidance is associated with symptom persistence after mild traumatic brain injury (mTBI). In this study, we investigated whether fear avoidance was associated with other outcomes such as return to work-related activity (RTW). MATERIALS AND METHODS: We analyzed associations between fear avoidance and RTW 6-9 months after mTBI, in two merged prospective mTBI cohorts. Adult participants aged 16 or over (n=175), presenting to outpatient services in New Zealand within 3 months of their injury, who were engaged in work-related activity at the time of injury, were included. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrollment and 6 months later. Associations between FAB-TBI scores and RTW outcome were analyzed using multivariate approaches. RESULTS: Overall, 53% of participants had RTW by 6-9 months after mTBI. While early fear avoidance was weakly associated with RTW, persistent high fear avoidance between study assessments or increasing avoidance with time were associated with greater odds of still being off work 6-9 months after injury. CONCLUSIONS: Pervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW 6-9 months after mTBI. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase after mTBI.

Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke.

BACKGROUND: Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes. OBJECTIVE: To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation. PARTICIPANTS: The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored. METHODS: Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach. RESULTS: Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics. CONCLUSION: The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.

The influence of psychological flexibility on persistent post concussion symptoms and functional status after mild traumatic brain injury.

PURPOSE: This study investigated the predictive role of psychological flexibility on long-term mTBI outcomes. METHOD: Adults with mTBI (N = 147) completed a context specific measure of psychological flexibility, (AAQ-ABI), psychological distress, and mTBI outcomes at less than three months post injury (M = 6.02 weeks after injury) and 6 months later (N = 102). Structural equation modelling examined the mediating effects of psychological flexibility on psychological distress and mTBI outcomes at six months. The direct effect of psychological flexibility at less than three months on mTBI outcomes at six months was entered into the model, plus pre-injury and injury risk factors. RESULTS: The theoretically derived model had good overall fit (χ2 = 1.42; p = 0.09; NFI = 0.95; TLI = 0.95; CFI = 0.98 and RMSEA = 0.06). Psychological flexibility at less than 3 months was directly significantly related to psychological distress and post-concussion symptoms at six months. Psychological flexibility at 6 months significantly mediated the relationship between psychological distress and functional disability but not post-concussion symptoms at six months post injury. CONCLUSION: The exploratory findings suggest that a context specific measure of psychological flexibility assessed acutely and in the chronic phase of recovery may predict longer-term mTBI outcomes.Implications for RehabilitationPersistent post-concussion symptoms (PPCS) after mild traumatic brain injury (mTBI) can have a significant impact on wellbeing, functional status, and quality of life.In this study, psychological flexibility early in recovery, was associated with higher levels of psychological distress and more severe post-concussion symptoms six months later.Psychological flexibility at six months post-injury also mediated the relationship between psychological distress and functional disability.A context specific measure of psychological flexibility may predict poorer long-term outcomes following mTBI.

Derivation of a minimal clinically important difference score for the WHODAS 2.0 in mild traumatic brain injury.

BACKGROUND: Mild traumatic brain injury (mTBI) treatment research is hindered by lack of clinically meaningful and responsive outcome measures. One promising measure is the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0), although minimal clinically important differences (MCID) for have not been established. OBJECTIVE: To estimate MCID for the WHODAS 2.0 for mTBI. METHODS: We analysed two prospectively collected mTBI datasets (n = 225) attending adult outpatient clinics in British Columbia, Canada. Participants completed the 12-item WHODAS 2.0, Patient Global Impression of Change scale, and Rivermead Post-Concussion Symptoms Questionnaire. We used anchor- and distribution-based methods to explore MCIDs in WHODAS 2.0 scores. RESULTS: For Study 1 (n = 131), the anchor and distribution-based approaches produced minimal change estimates ranging from 1.3 to 2.8 interval scores. For Study 2 (n = 94), the anchor and distribution-based approaches produced minimal change estimates from 2.2 to 3.2 interval scores. For certain subgroups based on age, sex, and post-concussion severity, minimal change estimates were slightly higher. CONCLUSION: An MCID of 3.5 interval WHODAS 2.0 points would conservatively capture meaningful change in adults of varying age, sex, and post-concussion symptom severity. Such a uniform metric will assist future mTBI intervention studies to improve standards of care and evaluation of outcomes.

Difficulties capturing co-occurring traumatic brain injury among people with traumatic spinal cord injury: a population-based study.

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

Psychological flexibility moderates the influence of fear avoidance on outcomes after mild traumatic brain injury.

OBJECTIVES: Psychological factors contribute to poorer long-term outcomes following mild traumatic brain injury (mTBI); however, the exact psychological mechanisms that underly this relationship are not well understood. This study examined the relationship between psychological flexibility, fear avoidance, and outcomes over the first 6 months after mTBI. METHOD: Adults with mTBI-completed measures of psychological flexibility, fear avoidance, post-concussion symptoms, and functional status at baseline (<3 months post-injury; N = 152), and 3-month (N = 133) and 6-month follow-up (N = 102). A conceptually derived moderation-mediation analysis was used to test the mediating effect of fear avoidance on post-concussion symptoms and functional outcomes, and the moderating effects of psychological flexibility on fear avoidance. RESULTS: Fear avoidance had a significant indirect effect on the relationship between post-concussion symptoms and functional status across all three time points. Psychological flexibility was found to significantly moderate these effects. Only low levels of psychological flexibility had a significant influence on the mediating effects of high fear avoidance on functional status at 6-month follow-up. CONCLUSIONS: Psychological flexibility may influence mTBI recovery by exerting an influence on fear avoidance. These initial findings provide a potential theoretical explanation of how fear avoidance can become maladaptive with time after mTBI.

Feasibility of Concussion Rehabilitation Approaches Tailored to Psychological Coping Styles: A Randomized Controlled Trial.

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.

Turning away from sound: The role of fear avoidance in noise sensitivity following mild traumatic brain injury.

BACKGROUND: Noise sensitivity (NS) following mild traumatic brain injury (mTBI) is common impacts functioning and outcomes. Recent research suggests psychological factors may have a significant role in the development of NS after mTBI. Psychological interventions have been advocated for to reduce this experience. To be effective, these interventions must aim to target the psychological processes that contribute to this relationship. Fear avoidance holds promise in this regard. The current study aimed to explore the role of fear avoidance in NS and examine its role in mediating the relationship between psychological distress and NS. METHOD: Adults (n = 234) diagnosed with mTBI were recruited from outpatient mTBI clinics throughout New Zealand. Participants completed self-report measures of pre-injury mental health status, as well as current post-concussion symptoms, psychological distress (anxiety, stress, depression, fear avoidance and post-traumatic stress symptoms) and functional status upon entry to an mTBI outpatient clinic (M = 8.9, SD = 9.2, post injury). RESULTS: A pre-injury mental health diagnosis was associated with NS after mTBI, as were symptoms of anxiety, stress, depression, and post-traumatic stress. Regression analyses revealed that fear avoidance (ß = 0.45, p = .01), as well as stress (ß = 0.07, p = .01) and PTSD symptoms (ß = 0.02, p = .01), made a significant and unique contribution to NS. A series of mediation analyses found that fear avoidance had a significant indirect effect on the relationships between psychological distress and NS. CONCLUSIONS: Fear avoidance is related to NS following mTBI. Targeting fear avoidance behaviours and beliefs may represent a treatment target for reducing NS after mTBI.

Do concussion clinicians use clinical practice guidelines?

OBJECTIVE: Clinical practice guidelines (CPGs) synthesize research evidence for health professionals and improve consistency of clinical care. However, it is unclear if concussion clinicians use them in their practice. We aimed to describe which CPGs New Zealand clinicians used and facilitators and barriers to uptake of these resources. MATERIALS AND METHODS: We used snowballing recruitment methods to survey New Zealand concussion clinicians. Descriptive statistics and qualitative description were used to evaluate survey responses. RESULTS: Ninety-six clinicians took part in the survey. A majority (70%) indicated they were aware of and had used at least one concussion CPG. Facilitators and barriers to using CPGs related to clinician experience, nature of the CPG, the work context, characteristics of clients and whether strategies were provided to encourage their use. CONCLUSIONS: Participants viewed concussion CPGs as helpful tools for informing clinical practice. That less experienced clinicians were less likely to use concussion CPGs than more experienced clinicians suggests there is an opportunity to develop strategies to improve the uptake of CPGs among newer clinicians. This and other areas of further research include how well CPGs capture relevant cultural factors and the role of case complexity in clinicians' willingness to use concussion CPGs.

The role of psychological flexibility in recovery following mild traumatic brain injury.

Purpose and Objective: Psychological distress is known to contribute to recovery following mild traumatic brain injury (mTBI) and there is a need to understand the mechanisms that contribute to this relationship. The present study examined psychological flexibility, as a hypothesized psychological mechanism, in 169 treatment-seeking adults with mTBI. Research Method/Design: Participants completed self-report measures of postconcussion symptoms, psychological distress (anxiety, stress, and depression) and functional status within four weeks of entry to an mTBI outpatient clinic. A general measure (Acceptance and Action Questionnaire), as well as a context-specific (Acceptance and Action Questionnaire-Acquired Brain Injury) measure of psychological flexibility were administered. Results: Simple linear regression analysis showed that psychological flexibility made a significant contribution to the prediction of postconcussion symptoms and functional status. A series of multiple mediation analyses also found that psychological flexibility had a significant indirect effect on the relationships between psychological distress and postconcussion symptoms, and functional status. The context-specific, rather than the general measure of psychological flexibility, was consistently shown to contribute to these findings. Conclusions/Implications: These results suggest that psychological flexibility is a psychological mechanism that contributes to recovery outcomes in individuals with mTBI and could therefore be an important treatment target in mTBI interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Development of a Programme Theory for Early Intervention Vocational Rehabilitation: A Realist Literature Review.

Purpose Little is currently known about how early intervention vocational rehabilitation (EIVR) works for people with newly acquired neurological conditions such as traumatic brain injury, acquired brain injury and spinal cord injury. This study aims, from a realist framework, to identify relevant literature and develop an initial programme theory to understand how EIVR might work for people experiencing acquired neurological disability. Realist reviews are ideally placed to address the identified knowledge gap as they assist in gaining a deeper understanding of how the intervention works, for whom it works best, and the contexts that promote the activation of desired outcomes. Methods We used a seven-step iterative process to synthesise literature using a realist approach. The steps included: development of initial programme theory, literature search, article selection, extracting and data organising, synthesis of evidence and programme theory refinement. We performed a literature search using the following databases: Cinahl, Embase, EMcare, Medline, PsychInfo and Scopus. Articles were selected if they contributed to the knowledge describing what is EIVR and how it works in newly acquired neurological conditions. Data were extracted and synthesised to develop a programme theory for EIVR. Results Following screening of 448 references, 37 documents were eligible for data extraction. We developed a refined programme theory of EIVR consisting of three contexts (prioritisation of exploring work options, return to work discussed as an option, and workplace support), nine mechanisms (ensuring rehabilitation teams' culture, fostering hope, exploring options, optimising self-efficacy, maintaining worker identity, staying connected, setting goals, engaging employer, and flexing roles) and three outcomes (confidence in ability to work, psychological adjustment, and engagement in solution focussed options). Conclusions This appears to be the first paper to explore how EIVR works, for whom and in what situations. We have produced a programme theory that may provide an initial understanding of EIVR following acquired neurological conditions.

Psychological flexibility in mild traumatic brain injury: an evaluation of measures.

PRIMARY OBJECTIVE: In this study, we examined the psychometric properties of measures of psychological flexibility in a mild traumatic brain injury (mTBI) sample. METHOD AND PROCEDURES: Adults who sustained a mTBI (n = 112) completed the Acceptance and Action Questionnaire - Acquired Brain Injury reactive avoidance subscale (AAQ-ABI (RA). Exploratory factor analysis and Rasch analysis were conducted to evaluate the facture structure, dimensionality, and differential item functioning. Construct validity was determined by correlating the AAQ-ABI (RA) with the Acceptance and Action Questionnaire-Revised (AAQ-II) and Fear Avoidance after Traumatic Brain Injury (FAB-TBI). MAIN OUTCOME AND RESULTS: The AAQ-ABI (RA) was found to have strong internal consistency (Cronbach's α = 0.87). Consistent with previous findings, the AAQ-ABI (RA) had one distinct factor. Fit to the unidimensional Rasch model was adequate (χ2 (18) = 22.5, p = .21) with no evidence of differential item functioning across person factors examined. The AAQ-ABI (RA) also had expected relationships with theoretically relevant constructs. CONCLUSIONS: The AAQ-ABI (RA) appears to be a psychometrically sound measure of psychological flexibility in mTBI.