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

  • Noah D. Silverberg
    Correspondence
    Corresponding author: Noah D. Silverberg, PhD, Rehabilitation Research Program, GF Strong Rehabilitation Centre, 4255 Laurel St, Vancouver, BC, Canada, V5Z 2G9
    Affiliations
    Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada

    Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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  • Molly Cairncross
    Affiliations
    Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada

    Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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  • Penelope M.A. Brasher
    Affiliations
    Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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  • Ana-Maria Vranceanu
    Affiliations
    Integrated Brain Health Clinical and Research Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States

    Harvard Medical School, Boston, MA, United States
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  • Deborah L. Snell
    Affiliations
    Concussion Clinic, Canterbury District Health Board, Christchurch, New Zealand

    Department of Orthopedic Surgery and Musculoskeletal Medicine, University of Otago, Dunedin, New Zealand
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  • Keith Owen Yeates
    Affiliations
    Department of Psychology, University of Calgary, Calgary, Alberta, Canada

    Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada

    Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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  • William J. Panenka
    Affiliations
    British Columbia Neuropsychiatry Program, Vancouver, British Columbia, Canada

    BC Mental Health and Substance Use Research Institute, Vancouver, British Columbia, Canada

    Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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  • Grant L. Iverson
    Affiliations
    Harvard Medical School, Boston, MA, United States

    Spaulding Rehabilitation Hospital, Boston, MA, United States

    Spaulding Research Institute, Boston, MA, United States

    MassGeneral Hospital for Children™ Sports Concussion Program, Boston, MA, United States

    Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, MA, United States
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  • Chantel T. Debert
    Affiliations
    Department of Clinical Neurosciences, Division of Physical Medicine and Rehabilitation, University of Calgary, Calgary, Alberta, Canada

    Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada

    Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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  • Mark T. Bayley
    Affiliations
    Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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  • Cindy Hunt
    Affiliations
    Head Injury Clinic, Trauma and Neurosurgery Program, St. Michael's Hospital, Toronto, Ontario, Canada

    Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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  • Andrew Baker
    Affiliations
    Head Injury Clinic, Trauma and Neurosurgery Program, St. Michael's Hospital, Toronto, Ontario, Canada
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  • Matthew J. Burke
    Affiliations
    Neuropsychiatry Program, Department of Psychiatry and Division of Neurology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada

    Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada

    Harvard Medical School, Boston, MA, United States
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  • on behalf of theCanadian Traumatic Brain Injury Research Consortium (CTRC)
Published:December 28, 2021DOI:https://doi.org/10.1016/j.apmr.2021.12.005

      Abstract

      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.

      Keywords

      List of abbreviations:

      BRIQ (Behavioral Response to Illness Questionnaire), FAB-TBI (Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire), GET (graded exposure therapy), Pacing+ (operant condition-based pacing strategies plus mindfulness training)
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