Objectives: Recent expert agreement statements and evidence-based practice guidelines for mild traumatic brain injury (mTBI) management no longer support advising patients to “rest until asymptomatic,” and instead recommend gradual return to activity after 1–2 days of rest. The present study aimed to: (i) document the current state of de-implementation of prolonged rest advice, (ii) identify patient characteristics associated with receiving this advice, and (iii) examine the relationship between exposure to this advice and clinical outcomes. Methods: In a case-control design, participants were prospectively recruited from two concussion clinics in Canada's public health care system. They completed self-report measures at clinic intake (Rivermead Post-concussion Symptom Questionnaire, Personal Health Questionnaire-9, and Generalized Anxiety Disorder-7) as well as a questionnaire with patient, injury, and recovery characteristics and the question: “Were you advised by at least one health professional to rest for more than 2 days after your injury?” Results: Of the eligible participants ( N = 146), 82.9% reported being advised to rest for more than 2 days (exposure group). This advice was not associated with patient characteristics, including gender (95% CI odds ratio = 0.48–2.91), race (0.87–6.28) age (0.93–1.01), a history of prior mTBI(s) (0.21–1.20), or psychiatric problems (0.40–2.30), loss of consciousness (0.23–2.10), or access to financial compensation (0.50–2.92). In generalized linear modeling, exposure to prolonged rest advice predicted return to productivity status at intake (B = −1.06, chi-squared(1) = 5.28, p = 0.02; 64.5% in the exposure group vs. 40.0% in the control were on leave from work/school at the time of clinic intake, 19.8 vs. 24% had partially returned, and 11.6 vs. 24% had fully returned to work/school). The exposure group had marginally (non-significantly) higher post-concussion, depression, and anxiety symptoms. Conclusions: mTBI patients continue to be told to rest for longer than expert recommendations and practice guidelines. This study supports growing evidence that prolonged rest after mTBI is generally unhelpful, as patients in the exposure group were less likely to have resumed work/school at 1–2 months post-injury. We could not identify patient characteristics associated with getting prolonged rest advice. Further exploration of who gets told to rest and who delivers the advice could inform strategic de-implementation of this clinical practice.

The Evidence Alliance (EA) is a Canada-wide multi-stakeholder organization providing national-level support in knowledge synthesis, clinical practice guidelines development, and knowledge translation. With a mandate to deliver the best available evidence to inform health policy and improve patient care, the EA involves patients and their caregivers in its governance, research priority setting and conduct, and capacity building. To reflect on the experiences of patient involvement in its first three years, the organization conducted a self-study with 17 actively involved patient partners. They answered the Patient Engagement in Research Scale 22-item short form (PEIRS-22) and open-ended questions. Of the 15 respondents, 12 were women with a mean age of 62.6 years (SD 10.1). The mean PEIRS-22 score was 82.1 (SD 15.9), indicating perceived meaningful engagement. Analysis of the free-text answers identified three themes: ( i) communication: successes, changes, and improvements; ( ii) a respectful and welcoming environment; and ( iii) opportunities to learn and contribute. Patient partners noted the EA made genuine efforts to welcome them and value their contributions. They also identified a need for the organization to increase patient partner diversity. This self-study was perceived as rewarding as it provided a foundation for further growth in patient involvement within the organization.

Background: Clinical practice guidelines for mild traumatic brain injury (mTBI) management call on family physicians to proactively screen and initiate treatment for mental health complications, but evidence suggests that this does not happen consistently. The authors aimed to identify physician-perceived barriers and facilitators to early management of mental health complications following mTBI. Methods & results: Semi-structured interviews based on the Theoretical Domains Framework (TDF) were conducted with 11 family physicians. Interview transcripts were analyzed using directed content analysis. Factors influencing management of mental health post-mTBI were identified along five TDF domains. Conclusion: Family physicians could benefit from accessible and easily implemented resources to manage post-mTBI mental health conditions, having a better defined role in this process, and formalization of referrals to mental health specialists.

Objective: To evaluate the feasibility and preliminary efficacy of a de-implementation intervention to support return-to-activity guideline use after concussion. Setting: Community. Participants: Family physicians in community practice (n = 21 at 5 clinics). Design: Pilot stepped wedge cluster randomized trial with qualitative interviews. Training on new guidelines for return to activity after concussion was provided in education outreach visits. Main Measures: The primary feasibility outcomes were recruitment, retention, and postencounter form completion (physicians prospectively recorded what they did for each new patient with concussion). Efficacy indicators included a knowledge test and guideline compliance based on postencounter form data. Qualitative interviews covered Theoretical Domains Framework elements. Results: Recruitment, retention, and postencounter form completion rates all fell below feasibility benchmarks. Family physicians demonstrated increased knowledge about the return-to-activity guideline (M = 8.8 true-false items correct out of 10 after vs 6.3 before) and improved guideline adherence (86% after vs 25% before) after the training. Qualitative interviews revealed important barriers (eg, beliefs about contraindications) and facilitators (eg, patient handouts) to behavior change. Conclusions: Education outreach visits might facilitate de-implementation of prolonged rest advice after concussion, but methodological changes will be necessary to improve the feasibility of a larger trial. The qualitative findings highlight opportunities for refining the intervention.

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BACKGROUND Despite the promising benefits of self-guided digital interventions for adolescents recovering from concussion, attrition rates are high. Exploring modifiable protective factors for participant engagement in self-guided digital interventions, including therapeutic alliance and social presence, is fundamental to preventing attrition. OBJECTIVE This open-label 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 (MBI). METHODS Adolescents ages 12-17.99 were recruited from a pediatric emergency department within 48 hours of sustaining a concussion (acute cohort) or through a tertiary care clinic over 1 month following a concussion (persisting symptoms cohort). Participants (N = 10) completed a 4-week MBI delivered via smartphone application. At 4-weeks, participants completed questionnaires and a semi-structured interview exploring their experience of therapeutic alliance and social presence with their asynchronous mindfulness guides in the intervention. RESULTS Quantitative and qualitative results revealed that participants developed therapeutic alliance and social presence with their guides, and that important factors to their development were guides’ personal backgrounds and the tone of their voices. Participants endorsed that therapeutic alliance and social presence were important for their engagement with the intervention. CONCLUSIONS These data suggest that therapeutic alliance and social presence can develop in interventions with limited synchronous human contact and may be important elements to participant engagement. Maximizing therapeutic alliance and social presence may be a promising way to reduce attrition in self-guided digital interventions while providing accessible and engaging treatment.

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IntroductionMental health problems frequently interfere with recovery from mild traumatic brain injury (mTBI) but are under-recognised and undertreated. Consistent implementation of clinical practice guidelines for proactive detection and treatment of mental health complications after mTBI will require evidence-based knowledge translation strategies. This study aims to determine if a guideline implementation tool can reduce the risk of mental health complications following mTBI. If effective, our guideline implementation tool could be readily scaled up and/or adapted to other healthcare settings.Methods and analysisWe will conduct a triple-blind cluster randomised trial to evaluate a clinical practice guideline implementation tool designed to support proactive management of mental health complications after mTBI in primary care. We will recruit 535 adults (aged 18–69 years) with mTBI from six emergency departments and two urgent care centres in the Greater Vancouver Area, Canada. Upon enrolment at 2 weeks post-injury, they will complete mental health symptom screening tools and designate a general practitioner (GP) or primary care clinic where they plan to seek follow-up care. Primary care clinics will be randomised into one of two arms. In the guideline implementation tool arm, GPs will receive actionable mental health screening test results tailored to their patient and their patients will receive written education about mental health problems after mTBI and treatment options. In the usual care control arm, GPs and their patients will receive generic information about mTBI. Patient participants will complete outcome measures remotely at 2, 12 and 26 weeks post-injury. The primary outcome is rate of new or worsened mood, anxiety or trauma-related disorder on the Mini International Neuropsychiatric Interview at 26 weeks.Ethics and disseminationStudy procedures were approved by the University of British Columbia’s research ethics board (H20-00562). The primary report for the trial results will be published in a peer-reviewed journal. Our knowledge user team members (patients, GPs, policymakers) will co-create a plan for public dissemination.Trial registration numberClinicalTrials.gov Registry (NCT04704037).