A good life for people living with disability: the story from Far North Queensland.

PURPOSE: People with disability in regional, rural and remote Australia have poorer service access compared to people from metropolitan areas. There is urgent need for reform. This study's aim was to explore the needs and aspirations of people with lived experience of disability in Far North Queensland (FNQ) to inform a new service framework. MATERIALS AND METHODS: Twenty-five individuals with diverse experience of disability were engaged in semi-structured interviews. Participants were recruited from four sites that differed geographically, culturally, and socioeconomically. Using an inductive then deductive thematic approach to data analysis, statements of needs and aspirations were compiled and aligned with three pre-determined vision statements. RESULTS: Needs and aspirations aligned well with the vision statements which were to: feel "included, connected, safe and supported"; have "opportunities to choose one's own life and follow one's hopes and dreams"; and have "access to culturally safe services close to home." To realise this vision in FNQ, support to navigate and coordinate services across sectors is essential. CONCLUSION: People of FNQ of all abilities, need and aspire to experience "a good life" like their fellow Australians. Any new service model must focus on providing service navigation and co-ordination amid the complexities of service delivery in FNQ.Implications for RehabilitationThe perspective of people with lived experience of disability needs to be heard and respected when designing services to support them.Service navigation and co-ordination are required to manage the complexity of service delivery for people living in regional, rural and remote Australia.Engaging with the whole the community is prudent when designing community disability, rehabilitation, and lifestyle services in regional, rural, and remote Australia.

A systematic review of disability, rehabilitation and lifestyle services in rural and remote Australia through the lens of the people-centred health care.

PURPOSE: The aim of this systematic review was to identify models of community disability, rehabilitation and lifestyle service delivery in non-metropolitan areas of Australia, and to describe these models through an Integrated People-Centred Health Services (IPCHS) lens. MATERIALS AND METHODS: We identified peer-reviewed studies published between 2000 and June 2021 that met the following criteria: described or evaluated a community service delivery model, intervention or program in regional, rural or remote Australia; provided for people with a disability or a potentially disabling health condition. A scoring rubric was developed covering the five IPCHS strategies. RESULTS: Nineteen studies were included in the review. We identified a range of service delivery models providing support to people with a range of disabilities or conditions. We report evidence of the use of the IPCHS strategies in ways relevant to the local context. DISCUSSION: Several strengths emerged, with many services tailored to individual need, and significant community engagement. Innovative rural service delivery approaches were also identified. Key areas requiring action included improved coordination or integration within and across professions and sectors. There was limited evidence of co-production of solutions or participatory governance. While people-centred approaches show promise to improve community-based services, large-scale fundamental change is required.IMPLICATIONS FOR REHABILITATIONCommunity-based disability and rehabilitation services in rural and remote Australia performed well at delivering tailored care and engaging in community consultation.These services must urgently implement strategies to enhance community ownership of solutions and participatory governance.Services must place a greater focus on explicit strategies to integrate and coordinate across services and professions, and to create an enabling environment, to deliver people-centred care.The World Health Organisation Integrated People-Centred Health Services framework provides an important roadmap to improving service delivery in rural and remote Australian communities.

Indigenous traumatic brain injury research: responding to recruitment challenges in the hospital environment.

BACKGROUND: Hospitals are common recruitment sites for injury and disability studies. However, the clinical and rehabilitation environment can create unique challenges for researchers to recruit participant populations. While there is growing injury and disability focused research involving Indigenous people to understand the types of services and supports required by this population to enhance their recovery experiences, there is limited knowledge of researchers' experiences implementing recruitment processes in the tertiary hospital environment. This paper reflects on the specific challenges of recruiting Indigenous patients following a traumatic brain injury from two tertiary hospitals in Northern Australia. METHODS: Between July 2016 and April 2018, research staff recruited eligible patients from one hospital in Queensland and one hospital in the Northern Territory. Qualitative records summarising research staff contact with patients, family members and clinical hospital staff were documented. These qualitative records, in addition to field trip notes and researcher reflections were reviewed to summarise the main challenges in gaining access to patients who fit the eligibility criteria. RESULTS: During the recruitment process, there were five main challenges encountered: (1) Patients discharging against medical advice from hospital; (2) Discharge prior to formal emergence from Post Traumatic Amnesia as per the Westmead Post Trauma Amnesia Scale; (3) Patients under adult guardianship orders; (4) Narrow participant eligibility criteria and (5) Coordinating around patient commitments and treatment. Details of how the recruitment processes were modified throughout the recruitment phase of the study to ensure greater access to patients that met the criteria are described. CONCLUSION: Based on our recruitment experiences, several recommendations are proposed for future TBI studies with Indigenous Australians. In addition to treatment, Indigenous TBI patients have wide range of needs that must be addressed while in hospital. Patient engagement and data collection processes should be flexible to respond to patient needs and the hospital environment. Employment of a centralized recruiter at each hospital site may help to minimise the challenges researchers need to navigate in the hospital environment. To improve recruitment processes in hospitals, it is essential for researchers examining other health or injury outcomes to describe their recruitment experiences.

Incidence of emergency department presentations for traumatic brain injury in Indigenous and non-Indigenous residents aged 15-64 over the 9-year period 2007-2015 in North Queensland, Australia.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of disability worldwide. Previous studies have shown that males have a higher incidence than females, and Indigenous populations have a higher rate than non-Indigenous. To date, no study has compared the incidence rate of TBI between Indigenous and non-Indigenous Australians for any cause. Here we add to this rather sparse literature. METHODS: Retrospective analysis of data from North Queensland Emergency Departments between 2007 and 2015 using Australian Bureau of Statistics population estimates for North Queensland residents aged 15-64 years as denominator data. Outcome measures include incidence rate ratios (IRR) for TBI presentations by Indigenous status, age, sex, year of presentation, remoteness, and socio-economic indicator. RESULTS: Overall incidence of TBI presentations per 100,000 population was 97.8. Indigenous people had an incidence of 166.4 compared to an incidence in the non-Indigenous population of 86.3, providing an IRR of 1.93 (95% CI 1.77-2.10; p < 0.001). Males were 2.29 (95% CI 2.12-2.48; p < 0.001) times more likely to present than females. Incidence increased with year of presentation only in the Indigenous male population. CONCLUSIONS: The greater burden of ED presentations for TBI in the Indigenous compared with the non-Indigenous population is of concern. Importantly, the need to provide quality services and support to people living with TBI in remote and very remote areas, and the major role of the new National Disability Insurance Scheme is discussed.

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review.

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents' motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

A systematic review of evaluated suicide prevention programs targeting indigenous youth.

BACKGROUND: Indigenous young people have significantly higher suicide rates than their non-indigenous counterparts. There is a need for culturally appropriate and effective suicide prevention programs for this demographic. AIMS: This review assesses suicide prevention programs that have been evaluated for indigenous youth in Australia, Canada, New Zealand, and the United States. METHOD: The databases MEDLINE and PsycINFO were searched for publications on suicide prevention programs targeting indigenous youth that include reports on evaluations and outcomes. Program content, indigenous involvement, evaluation design, program implementation, and outcomes were assessed for each article. RESULTS: The search yielded 229 articles; 90 abstracts were assessed, and 11 articles describing nine programs were reviewed. Two Australian programs and seven American programs were included. Programs were culturally tailored, flexible, and incorporated multiple-levels of prevention. No randomized controlled trials were found, and many programs employed ad hoc evaluations, poor program description, and no process evaluation. CONCLUSION: Despite culturally appropriate content, the results of the review indicate that more controlled study designs using planned evaluations and valid outcome measures are needed in research on indigenous youth suicide prevention. Such changes may positively influence the future of research on indigenous youth suicide prevention as the outcomes and efficacy will be more reliable.

A service-level action research intervention to improve identification and treatment of cannabis and related mental health issues in young Indigenous Australians: a study protocol.

INTRODUCTION: Regular cannabis use is associated with negative mental health impacts including psychosis, depression and anxiety. Rates of cannabis use have increased in Aboriginal and Torres Strait Islander communities in northern Australia within the last two decades, presenting a significant increased risk to young people's mental health in these regions. Improved screening, early detection and treatment for cannabis-related mental health issues are urgently required. This paper describes a service-level action research intervention and evaluation protocol for use in the few services where it is possible to engage young Aboriginal and Torres Strait Islander Australians. METHODS/DESIGN: The protocol is being developed in two services where youth mental health is core business: a primary healthcare centre and a youth service in the Cairns and hinterland region, far north Queensland. The protocol calls first for baseline data to be collected using staff and client surveys; network mapping; and analysis of screening, treatment and referral rates. The protocol's intervention phase is driven by service needs identified from baseline data. Intervention strategies focus on implementing/enhancing cannabis screening instruments and processes in line with current best practice; enhancing networks with external drug and mental health services; developing culturally acceptable training and resources; developing activities aiming to reduce cannabis use in young Aboriginal and Torres Strait Islander clients using the services. The protocol requires implementation of the multilevel intervention within each service for 1 year, with follow-up data then collected and compared to baseline. Process evaluation identifies the more effective intervention strategies and documents the challenges to be overcome for full implementation. ETHICS AND DISSEMINATION: Ethics approval was provided by The James Cook University, Human Research Ethics Committee. Ethics Approval Number H5322. Peer-reviewed publications will also be used to disseminate the finding. Results will also be discussed with stakeholder organisations.

Functional magnetic resonance imaging of working memory in Huntington's disease: cross-sectional data from the IMAGE-HD study.

We used functional magnetic resonance imaging (fMRI) to investigate spatial working memory (WM) in an N-BACK task (0, 1, and 2-BACK) in premanifest Huntington's disease (pre-HD, n = 35), early symptomatic Huntington's disease (symp-HD, n = 23), and control (n = 32) individuals. Overall, both WM conditions (1-BACK and 2-BACK) activated a large network of regions throughout the brain, common to all groups. However, voxel-wise and time-course analyses revealed significant functional group differences, despite no significant behavioral performance differences. During 1-BACK, voxel-wise blood-oxygen-level-dependent (BOLD) signal activity was significantly reduced in a number of regions from the WM network (inferior frontal gyrus, anterior insula, caudate, putamen, and cerebellum) in pre-HD and symp-HD groups, compared with controls; however, time-course analysis of the BOLD response in the dorsolateral prefrontal cortex (DLPFC) showed increased activation in symp-HD, compared with pre-HD and controls. The pattern of reduced voxel-wise BOLD activity in pre-HD and symp-HD, relative to controls, became more pervasive during 2-BACK affecting the same structures as in 1-BACK, but also incorporated further WM regions (anterior cingulate gyrus, parietal lobe and thalamus). The DLPFC BOLD time-course for 2-BACK showed a reversed pattern to that observed in 1-BACK, with a significantly diminished signal in symp-HD, relative to pre-HD and controls. Our findings provide support for functional brain reorganisation in cortical and subcortical regions in both pre-HD and symp-HD, which are modulated by task difficulty. Moreover, the lack of a robust striatal BOLD signal in pre-HD may represent a very early signature of change observed up to 15 years prior to clinical diagnosis.

Aboriginal people in remote communities in Arnhem Land (Northern Territory) restrict their smoking in some environments: Implications for developing and implementing interventions to reduce exposure to environmental tobacco smoke.

INTRODUCTION AND AIMS: In Arnhem Land's remote Aboriginal communities [Northern Territory], very high smoking rates and overcrowding mean high exposure to Environmental Tobacco Smoke. This study compared smokers who restrict their smoking in these environments with those who do not. DESIGN AND METHODS: In 2008-2009, 258 smokers (137 males and 121 females) aged ≥ 16 years, provided information permitting categorisation of those who 'RESTRICT' their smoking in the house, car or workplace from those who do 'NOT RESTRICT'. Univariable and multivariable logistic regressions compared 'RESTRICT' and 'NOT RESTRICT' groups by gender, age group, daily use, tobacco consumption, time-to-first-cigarette and quit intentions. Those in the 'RESTRICT' group explained their motivations, summarised using qualitative data analysis. RESULTS: Men were almost twice as likely to 'NOT RESTRICT' their smoking (odds ratio = 1.88, 95% confidence interval = 1.14-3.08, P = 0.013). Time-to-first-cigarette was the strongest predictor to 'NOT RESTRICT' in women (odds ratio = 3.48, 95% confidence interval = 1.44-8.41, P = 0.006) with daily consumption the strongest predictor in men (odds ratio = 3.15, 95% confidence interval = 1.39-7.18, P = 0.006). Men and women shared similar motivations for restricting smoking. DISCUSSION AND CONCLUSIONS: Smoke-free homes and workplaces are important opportunities to reduce exposure to Environmental Tobacco Smoke in remote Indigenous communities.

An exploratory study of cannabis withdrawal among Indigenous Australian prison inmates: study protocol.

INTRODUCTION: Cannabis use and dependence is a serious health and criminal justice issue among incarcerated populations internationally. Upon abrupt, enforced cessation of cannabis, prisoners may suffer irritability and anger that can lead to threatening behaviour, intimidation, violence, sleep disturbances and self-harm. Cannabis withdrawal syndrome, proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders in 2013, has not been examined in Indigenous populations. Owing to the exceptionally high rates of cannabis use in the community, high proportions of Australian Indigenous prisoners may suffer from withdrawal upon entry to custody. METHODS AND ANALYSIS: 60 male and 60 female Indigenous prisoners (18-40 years) at a high risk of cannabis dependence will be recruited upon entry to custody. A pictorial representation of the standard Cannabis Withdrawal Scale will be tested for reliability and validity. Cortisol markers will be measured in saliva, as the indicators of onset and severity of cannabis withdrawal and psychological distress. The characteristics will be described as percentages and mean or median values with 95% CI. Receiver operator curve analysis will determine an ideal cut-off of the Cannabis Withdrawal Scale and generalised estimating equations modelling will test changes over time. The acceptability and efficacy of proposed resources will be assessed qualitatively using thematic analysis. OUTCOMES: A valid and reliable measure of cannabis withdrawal for use with Indigenous populations, the onset and time course of withdrawal symptoms in this population and the development of culturally acceptable resources and interventions to identify and manage cannabis withdrawal. ETHICS AND DISSEMINATION: The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4651).The results will be reported via peer reviewed publications, conference, seminar presentations and on-line media for national and international dissemination.

Stages of change, smoking behaviour and readiness to quit in a large sample of indigenous Australians living in eight remote north Queensland communities.

Tobacco smoking is a major health issue for Indigenous Australians, however there are few interventions with demonstrated efficacy in this population. The Transtheoretical Model may provide a useful framework for describing smoking behaviour and assessing readiness to quit, with the aim of developing better interventions. Interviews were conducted with 593 Indigenous Australians in eight rural and remote communities in north Queensland, to examine stages of change and smoking behaviour. Among current smokers, 39.6% and 43.4% were in Precontemplation and Contemplation stages respectively. A further 13.9% were making preparations to quit (Preparation) whilst only 3.2% said they were actively trying to quit (Action). When analysed by stage of change, the pattern of smoking-related behaviours conformed to the results of past research using the model. Importantly however, distribution of individuals across the stages opposes those observed in investigations of smoking behaviour in non-Indigenous Australian populations. The Transtheoretical Model can be used to meaningfully classify Indigenous smokers in remote north Queensland according to stages along the behaviour change continuum. Importantly, in this large sample across eight communities, most Indigenous smokers were not making preparations to change their smoking behaviour. This suggests that interventions should focus on promoting movement toward the Preparation and Action stages of change.

Description and psychometric properties of the CP QOL-Teen: a quality of life questionnaire for adolescents with cerebral palsy.

To assess the measurement properties of a new QOL instrument, the Cerebral Palsy Quality of Life Questionnaire-Teen (CP QOL-Teen), in adolescents with cerebral palsy (CP) aged 13-18 years, examining domain structure, reliability, validity and adolescent-caregiver concordance. Based on age, 695 eligible families were invited to participate by mail. Questionnaires were returned by 112 primary caregivers (71.8% of questionnaires sent). 87 adolescents aged 12-18 years also completed the questionnaires. CP QOL-Teen, generic QOL instruments (KIDSCREEN, Pediatric Quality of Life Inventory), functioning (Gross Motor Function Classification System) and a condition-specific instrument (PedsQL-CP) were used. Principal components analysis produced seven scales: wellbeing and participation; communication and physical health; school wellbeing; social wellbeing; access to services; family health; feelings about functioning. Cronbach's alphas for the derived scales ranged from 0.81 to 0.96 (primary caregiver report) and 0.78 to 0.95 (adolescent report). Test-retest reliability (4 weeks) ranged from 0.57 to 0.88 for adolescent self-report and 0.29 to 0.83 for primary caregiver report. Moderate correlations were observed with other generic and condition specific measures of QOL, indicating adequate construct validity. Moderate correlations were observed between adolescent self-report and primary caregiver proxy report. This study demonstrates acceptable psychometric properties of both the adolescent self-report and the primary caregiver proxy report versions of the CP QOL-Teen.

Detecting psychotic symptoms in Indigenous populations: a review of available assessment tools.

As efforts to shorten the duration of untreated psychosis increase, there is a need for short screening instruments to identify those at-risk. It is feared that remote Indigenous populations, manifesting many of the risk factors associated with schizophrenia and often lacking access to adequate mental health services, may be overlooked as the general population effort shifts towards early detection. This article aimed to review studies investigating psychotic symptoms in Indigenous communities in Australia, New Zealand, Canada and United States of America and aimed to evaluate the usefulness of the instruments. Eleven relevant studies were identified using seven unique instruments. The available instruments assessed psychotic symptoms to varying degrees, although no screener for early detection was found thus supporting concerns that these disadvantaged populations do not have access to suitable support enabling early detection of psychosis. We recommend that a rapid screening tool for detecting at-risk individuals be developed and validated for community use in Indigenous populations living in remote areas.

Media guidelines for the responsible reporting of suicide: a review of effectiveness.

BACKGROUND: The media have a powerful influence on those at risk of suicide. Evidence linking sensational media reporting with imitative suicidal behavior continues to grow, prompting the widespread development of guidelines for media professionals on the reporting of suicide. While such guidelines have been widely implemented, only a small amount of research has addressed their use and effectiveness. AIMS: To conduct a systematic literature review aimed at critically evaluating the evidence concerning the use and effectiveness of media guidelines for reporting on suicide. METHODS: All research publications that addressed the effectiveness of media guidelines against a variety of outcome measures were examined. RESULTS: The findings highlight cases in which guideline implementation has successfully mitigated imitative suicides. Significant variability in the effect of guidelines on the quality of suicide reporting was observed between studies, and research suggests journalist awareness, use, and opinion of guidelines is generally low. The critical positive effects of media collaboration and training on reporting are noted. CONCLUSIONS: Overall, the findings of this review suggest that the guidelines can change reporting style and prevent imitative suicide, but that approaches centered on consultation, collaboration, media ownership, and training are likely to achieve the greatest success.

The role of an open-space CCTV system in limiting alcohol-related assault injuries in a late-night entertainment precinct in a tropical Queensland city, Australia.

Closed circuit television (CCTV) systems which incorporate real-time communication links between camera room operators and on-the-ground security may limit injuries resulting from alcohol-related assault. This pilot study examined CCTV footage and operator records of security responses for two periods totalling 22 days in 2010-2011 when 30 alcohol-related assaults were recorded. Semistructured discussions were conducted with camera room operators during 18 h of observation. Camera operators were proactive, efficiently directing street security to assault incidents. The system intervened in 40% (n=12) of alcohol-related assaults, limiting possible injury. This included three incidents judged as potentially preventable. A further five (17%) assault incidents were also judged as potentially preventable, while 43% (n=13) happened too quickly for intervention. Case studies describe security intervention in each category. Further research is recommended, particularly to evaluate the effects on preventing injuries through targeted awareness training to improve responsiveness and enhance the preventative capacity of similar CCTV systems.

Cannabis use in Cape York Indigenous communities: high prevalence, mental health impacts and the desire to quit.

INTRODUCTION AND AIMS: Anecdotal reports suggest that high rates of cannabis use and dependence are significant issues in Indigenous communities in north Queensland; however, there is little scientific evidence to support or refute this. The Cape York Cannabis Project seeks to investigate cannabis use rates, cannabis dependence and mental health impacts for the first time in three Cape York Indigenous communities. DESIGN AND METHODS: The current study reports preliminary findings, resulting from interviews with 133 Indigenous participants aged 14-47 years from one Cape York community. Quantitative data were gathered on rates of cannabis use, cannabis dependence as measured by a score of ≥ 3 the Severity of Dependence Scale. Qualitative self-report data were gathered concerning mental health impacts of cannabis and reasons for quitting. RESULTS AND CONCLUSIONS: Very high rates of cannabis use were identified, with 66.2% of males and 30.5% of females interviewed being current users. An additional 12.2% of males and 30.5% of females were former users, and 21.6% of males and 39% of females had never used cannabis. High rates of cannabis dependence were also observed. Of those current users who used cannabis at least weekly, 67.7% reported cannabis dependence. A range of mental health impacts due to cannabis were reported. In total, 76.1% of current users were considering quitting or cutting down. Rates of use and dependence were much higher than national rates, and indicate significant mental health harms due to cannabis. Further investigation of mental health impacts of cannabis is required, as is intervention to reduce these impacts.

Connectivity-based segmentation of the striatum in Huntington's disease: vulnerability of motor pathways.

The striatum, the primary site of degeneration in Huntington's disease (HD), connects to the cerebral cortex via topographically organized circuits subserving unique motor, associative and limbic functions. Currently, it is not known whether all cortico-striatal circuits are equally affected in HD. We aimed to study the selective vulnerability of individual cortico-striatal circuits within the striatum in HD, and hypothesized that motor cortico-striatal pathways would be most affected, consistent with HD being a primarily motor disorder. Diffusion Tensor Imaging (DTI) tractography was used to identify connections between the striatum and seven major cortical regions in 12 HD patients and 14 matched controls. The striatum of both groups was parcellated into subregions based on connectivity with the cerebral cortex. Volumetric and DTI microstructural measures of Fractional Anisotropy (FA) and Mean Diffusivity (MD) were obtained within each subregion and compared statistically between groups. Tractography demonstrated the topographic organization of cortical connections in the striatum of both controls and HD patients. In HD patients, the greatest difference from controls in volume, FA and MD was observed in M1 and S1 subregions of the caudate and putamen. Motor symptoms correlated with volume and MD in sensorimotor striatal subregions, suggesting that sensorimotor striatal degeneration is closely related to motor dysfunction. DTI tractography provides a novel approach to sensitively examine circuit-specific abnormalities in HD and has identified that the motor cortico-striatal circuit is selectively vulnerable in HD.

Diffusion tensor imaging in Huntington's disease reveals distinct patterns of white matter degeneration associated with motor and cognitive deficits.

White matter (WM) degeneration is an important feature of Huntington's disease (HD) neuropathology. To investigate WM degeneration we used Diffusion Tensor Imaging and Tract-Based Spatial Statistics to compare Fractional Anisotropy, Mean Diffusivity (MD), parallel diffusivity and perpendicular diffusivity (λ⊥) in WM throughout the whole brain in 17 clinically diagnosed HD patients and 16 matched controls. Significant WM diffusivity abnormalities were identified primarily in the corpus callosum (CC) and external/extreme capsules in HD patients compared to controls. Significant correlations were observed between motor symptoms and MD in the CC body, and between global cognitive impairment and λ⊥ in the CC genu. Probabilistic tractography from these regions revealed degeneration of functionally relevant interhemispheric WM tracts. Our findings suggest that WM degeneration within interhemispheric pathways plays an important role in the deterioration of cognitive and motor function in HD patients, and that improved understanding of WM pathology early in the disease is required.