Is MRI screening for bone marrow oedema useful in predicting lumbar bone stress injuries in adult male professional cricketers? A New Zealand pilot study.

OBJECTIVES: The aims were to (1) prospectively observe the incidence of bone marrow oedema in asymptomatic adult male domestic professional cricketers during a season and evaluate its relationship to the development of lumbar bone stress injury and (2) further understand the practicalities of implementing a Magnetic Resonance Imaging-based screening program to prevent lumbar bone stress injury in New Zealand cricket. DESIGN: Prospective observational cohort. METHODS: Adult male pace bowlers received 6-weekly pre-planned Magnetic Resonance Imaging scans over a single season to determine the presence and intensity of bone marrow oedema in the posterior vertebral arches of the lumbar spine. The participants bowling volume and back pain levels were monitored prospectively. RESULTS: 22 participants (mean age 25.3 years (range 20-32 years)) completed all 4 scans. Ten participants had a prior history of lumbar bone stress injury. Ten participants (45 %, 95 % confidence interval 24-68 %) had bone marrow oedema evident on at least one scan, with 9 (41 %) participants recording a bone marrow oedema intensity ≥ 2 and 5 (23 %) participants demonstrated an intensity ≥ 3. During the study one participant was diagnosed with a lumbar bone stress reaction. No participants developed a lumbar bone stress fracture. CONCLUSIONS: Due to the lower incidence of lumbar bone stress injuries in adult bowlers coupled with uncertainty over appropriate threshold values for bone marrow oedema intensity, implementation of a resource intense screening program aimed at identifying adult domestic cricketers at risk of developing a lumbar bone stress injury is not currently supported.

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.

Co-design of a therapeutic virtual reality tool to increase awareness and self-management of cognitive fatigue after traumatic brain injury.

PURPOSE: The symptom of cognitive fatigue is reported as one of the longest lasting and most debilitating symptoms of traumatic brain injury (TBI). Virtual reality may be one of the most suitable technologies for neurorehabilitation, able to integrate evidence-based neuroscientific principles into motivating rehabilitation simulations. The purpose of this study was to seek perspectives of individuals with lived experience of TBI and experienced rehabilitation clinicians in the co-design of a novel technology-based tool for cognitive fatigue after TBI. MATERIALS AND METHOD: Co-design focus groups with a sample of clinicians and individuals with lived experience of TBI were used to identify the design parameters. A prototype was developed using inter-disciplinary design iterations. Focus groups were repeated with participants testing the prototype. Qualitative data were analysed using a general inductive approach. RESULTS: Feasibility of VR in this population was well tolerated. The focus groups guided development of domains including environment, tasks, level progression, outcome measures and considerations about clinical implementation of VR. CONCLUSIONS: By merging advancements in VR science with a translational approach, a co-designed virtual reality tool to increase awareness and self-management of cognitive fatigue has been developed, suitable for use in persons with TBI.Implications for rehabilitationImmersive virtual reality tools show promise for addressing awareness of cognitive fatigue after traumatic brain injury in rehabilitation settings.Early engagement with consumers is recommended to produce a usable rehabilitation product.

Developing spinal cord injury physiotherapy clinical practice guidelines: a qualitative study to determine how physiotherapists and people living with spinal cord injury use evidence.

STUDY DESIGN: Generic qualitative design. OBJECTIVES: Australian and New Zealand SCI physiotherapists are developing clinical practice guidelines for the physiotherapy management of people living with spinal cord injury. To guide the development of the guidelines it was important to understand how physiotherapists and people living with spinal cord injury use evidence to choose interventions and the potential barriers and facilitators to the uptake of the clinical practice guidelines. SETTING: Spinal Cord Injury Centres in Sydney, Australia and New Zealand. METHODS: Focus groups and interviews with physiotherapists and people living with spinal cord injury were recorded, transcribed, and subjected to thematic analysis. RESULTS: A total of 75 participants took part in the study, 45 physiotherapists and 30 people living with spinal cord injury. Three main themes were identified from the data: (1) Types and sources of evidence that influence treatment choices, (2) the many factors determining treatment choices, and (3) ways in which clinical practice guidelines could influence treatment. CONCLUSIONS: Clinical practice guidelines have the potential to reduce the barriers identified by physiotherapists in accessing and interpreting research evidence on interventions for people living with spinal cord injury. Supported implementation of guidelines is required to demonstrate their benefit and encourage physiotherapists to factor in evidence when balancing the multiple factors influencing choice of physiotherapy intervention.

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.

Flourishing together: research protocol for developing methods to better include disabled people's knowledge in health policy development.

BACKGROUND: To positively impact the social determinants of health, disabled people need to contribute to policy planning and programme development. However, they report barriers to engaging meaningfully in consultation processes. Additionally, their recommendations may not be articulated in ways that policy planners can readily use. This gap contributes to health outcome inequities. Participatory co-production methods have the potential to improve policy responsiveness. This research will use innovative methods to generate tools for co-producing knowledge in health-related policy areas, empowering disabled people to articulate experience, expertise and insights promoting equitable health policy and programme development within Aotearoa New Zealand. To develop these methods, as an exemplar, we will partner with both tangata whaikaha Maori and disabled people to co-produce policy recommendations around housing and home (kainga)-developing a nuanced understanding of the contexts in which disabled people can access and maintain kainga meeting their needs and aspirations. METHODS: Participatory co-production methods with disabled people, embedded within a realist methodological approach, will develop theories on how best to co-produce and effectively articulate knowledge to address equitable health-related policy and programme development-considering what works for whom under what conditions. Theory-building workshops (Phase 1) and qualitative surveys (Phase 2) will explore contexts and resources (i.e., at individual, social and environmental levels) supporting them to access and maintain kainga that best meets their needs and aspirations. In Phase 3, a realist review with embedded co-production workshops will synthesise evidence and co-produce knowledge from published literature and non-published reports. Finally, in Phase 4, co-produced knowledge from all phases will be synthesised to develop two key research outputs: housing policy recommendations and innovative co-production methods and tools empowering disabled people to create, synthesise and articulate knowledge to planners of health-related policy. DISCUSSION: This research will develop participatory co-production methods and tools to support future creation, synthesis and articulation of the knowledge and experiences of disabled people, contributing to policies that positively impact their social determinants of health.

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.

Early vocational rehabilitation for people with spinal cord injury: a research protocol using realist synthesis and interviews to understand how and why it works.

INTRODUCTION: Return to work after spinal cord injury (SCI) is linked to well-being and better physical and mental health outcomes. In New Zealand, work rates after SCI are lower than the general population. Vocational rehabilitation is one method of supporting return to work. Although the best model has not been determined, there is evidence supporting early intervention. However, most vocational rehabilitation research focuses on return to work outcomes without considering why vocational rehabilitation works, for whom and under what circumstances. Given this knowledge gap, we detail a realist synthesis protocol aiming to explain how contextual factors trigger relevant mechanisms to facilitate return to work after SCI. METHODS AND ANALYSIS: This study will use a realist synthesis approach, following Realist And MEta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. First, we will undertake a realist review of existing published and grey literature. Second, to assist with theoretical conceptualisation, we will interview people with SCI who have received vocational rehabilitation. Finally, we will survey people with SCI who received early vocational rehabilitation for theoretical testing and refinement. ETHICS AND DISSEMINATION: University of Otago Ethics Committee (Reference H19/170) has been obtained. A knowledge translation event will address issues relevant to wider implementation of the intervention and study findings. Findings will be also be disseminated through peer reviewed journals, conference presentations and formal reports.

Access to community support workers during hospital admission for people with spinal cord injury: a pilot study.

STUDY DESIGN: A descriptive qualitative study. OBJECTIVES: To evaluate a pilot project enabling people with spinal cord injury (SCI) to have their support workers accompany them into a non-SCI specialist/public hospital (excluding ICU) to perform selected care. SETTING: The study was conducted in New Zealand. METHODS: Interviews and focus groups with people with SCI, support workers, care agency staff, and hospital staff who participated in the pilot project. RESULTS: Twenty-five individuals participated in the study. Two themes captured participants' experiences of the pilot: 'Maintaining individualised care' and 'Role, tasks and responsibilities. Support workers were described as knowledgeable about SCI care needs and being better positioned to provide individualised care for people with SCI than general nursing staff. Participants with SCI felt less anxious having a support worker with them, and perceived less risk of acquiring secondary health complications during the hospital admission. Good communications is important to ensure there is a shared understanding of the role and responsibilities of having an unregistered support worker in the hospital environment. CONCLUSIONS: Having their regular support worker during admission to public hospital improved the SCI-specific care received. Support workers reduced the demand on hospital nursing staff who did not always have the time or specialist SCI knowledge to provide individualised care. People with SCI may be more likely to access medical assistance earlier and not defer hospital admissions if they can have support workers accompany them into hospital.

Epidemiology of traumatic spinal cord injury in New Zealand (2007-2016).

AIM: To investigate the epidemiology of traumatic spinal cord injury (TSCI) in New Zealand over a 10-year period. METHODS: Ambispective data of all new patients admitted to New Zealand's two spinal rehabilitation units between January 2007 and December 2016 (n=929) were collated. Variables assessed included age at injury, gender, ethnicity, date of injury, aetiology, length of hospital stay, injury level, neurological status on discharge and discharge destination. RESULTS: The incidence of TSCI averaged 22 (95% CI 21-24) per million, increasing 6% a year. The average incidence for Maori (29 per million people (95% CI 25-34)) was 1.8 times higher than New Zealand European (16 per million people (95% CI 15-18)), and show an increase of 14% a year. The median age of TSCI increased from 43 to 48 years. Overall, falls (32%), transport (32%) and sports (22%) were the most common causes of TSCI. Cervical TSCI (54%) were most common, particularly in older adults (70% over 75 years) and Maori (61%) and Pacific Island (72%) patients. Surgical rates remained stable (77%) but length of stay in hospital decreased over the study period. CONCLUSIONS: The demographic of TSCI is changing in New Zealand. The median age of patients is increasing, as is the incidence, particularly for women, older adults and Maori patients.

Using cannabis for pain management after spinal cord injury: a qualitative study.

Study design: A descriptive qualitative study. Objectives: To explore why individuals with spinal cord injury (SCI) choose to use cannabis to manage their pain and their experiences in doing so. Setting: Community-dwelling adults with SCI in New Zealand. Methods: Semi-structured interviews were conducted with individuals who had a SCI, experienced pain, and self-reported use of cannabis to manage their pain. Interviews were recorded, transcribed, and subject to thematic analysis. Results: Eight individuals participated in this study. We interpreted six themes that captured the participants' perspectives regarding their choice to, and perceptions of, using cannabis to manage SCI pain. Participants were motivated to use cannabis when other pain management strategies had been ineffective and were well-informed, knowledgeable cannabis consumers. Participants reported cannabis reduced their pain quickly and enabled them to engage in activities of daily living and participate in life roles without the drowsiness of traditional prescribed pain medication. Despite the positive aspects, participants were concerned about the irregularity of supply and inconsistent dosage. Conclusions: Findings show that cannabis is used to reduce pain after SCI and enable increased community participation. Findings suggest that future studies examining the efficacy of cannabinoids in managing pain include function and participation outcome measures rather than solely focusing on measuring pain intensity. Focusing on meaningful outcomes may contribute to a greater understanding of the experiences of people with SCI.

Relationships and the transition from spinal units to community for people with a first spinal cord injury: A New Zealand qualitative study.

BACKGROUND: Spinal Cord Injury (SCI) can have substantial consequences for the injured person, and also their family/whanau (Maori word for extended family and social networks). Family members can adopt either formal or informal care roles when the person returns home, and people with high-level care requirements may also need non-family support workers. OBJECTIVE: This study considers how SCI can impact relationships during the transition from spinal rehabilitation units to home. METHOD: Nineteen SCI participants from the New Zealand longitudinal study were interviewed six months post-discharge from either of New Zealand's two spinal units. Data were analysed using the framework method. RESULTS: Three themes captured participants' relationship experiences during the time of transition: Role Disruption, examines how participants' pre-SCI family/whanau relationships underwent change as previously understood parameters of engagement were disrupted. A Balancing Act, explores the challenge of renegotiating previously-understood parameters between participants and whanau. The Stranger in My/Our Room focuses on how the relationship between participants and support workers was (necessarily) new to the participant and their family/whanau who now had an 'outsider' episodically or continuously in their home. The specifics of 'their' relationship was also new to the support worker; and negotiating the parameters of this relationship could only occur on transition home. CONCLUSION: SCI necessitates a renegotiation of relationships and, for some, also involves the negotiation of a new type of relationship with support workers. Understanding the ways a SCI may affect relationships can enable rehabilitation services to best support people with SCI and their family to prepare for their transition home.

Training wheelchair navigation in immersive virtual environments for patients with spinal cord injury - end-user input to design an effective system.

PURPOSE: A user-centred design was used to develop and test the feasibility of an immersive 3D virtual reality wheelchair training tool for people with spinal cord injury (SCI). METHOD: A Wheelchair Training System was designed and modelled using the Oculus Rift headset and a Dynamic Control wheelchair joystick. The system was tested by clinicians and expert wheelchair users with SCI. Data from focus groups and individual interviews were analysed using a general inductive approach to thematic analysis. RESULTS: Four themes emerged: Realistic System, which described the advantages of a realistic virtual environment; a Wheelchair Training System, which described participants' thoughts on the wheelchair training applications; Overcoming Resistance to Technology, the obstacles to introducing technology within the clinical setting; and Working outside the Rehabilitation Bubble which described the protective hospital environment. CONCLUSIONS: The Oculus Rift Wheelchair Training System has the potential to provide a virtual rehabilitation setting which could allow wheelchair users to learn valuable community wheelchair use in a safe environment. Nausea appears to be a side effect of the system, which will need to be resolved before this can be a viable clinical tool. Implications for Rehabilitation Immersive virtual reality shows promising benefit for wheelchair training in a rehabilitation setting. Early engagement with consumers can improve product development.

Return to work for severely injured survivors of the Christchurch earthquake: influences in the first 2 years.

PURPOSE: This study looked at the influences on the return to work (RTW) in the first 2 years for people severely injured in the 22 February 2011 Christchurch earthquake. METHOD: We used a constructivist grounded theory approach using semi-structured interviews to collect data from 14 people injured in the earthquake. RESULTS: Analysis elicited three themes that appeared to influence the process of RTW following the Christchurch earthquake. Living the earthquake experience, the individual's experiences of the earthquake and how their injury framed their expectations; rebuilding normality, the desire of the participants to return to life as it was; while dealing with the secondary effects of the earthquake includes the earthquake specific effects which were both barriers and facilitators to returning to work. CONCLUSION: The consequences of the earthquake impacted on experience, process and outcome of RTW for those injured in the Christchurch Earthquake. Work and RTW appeared key tools to enhance recovery after serious injury following the earthquake. IMPLICATIONS FOR REHABILITATION: The altered physical, social and economic environment must be considered when working on the return to work (RTW) of individuals with earthquake injuries. Providing tangible emotional and social support so injured earthquake survivors feel safe in their workplace may facilitate RTW. Engaging early with employers may assist the RTW of injured earthquake survivors.

Participation and quality of life outcomes among individuals with earthquake-related physical disability: A systematic review.

OBJECTIVE: A literature review to evaluate quality of life and participation outcomes of individuals with earthquake-related physical injury. DATA SOURCES: A systematic review was performed using National Health Service (NHS) Centre for Reviews and Dissemination (CRD) guidelines. MEDLINE, Embase, PsychINFO, CINAHL and AMED electronic databases were searched from 1966 to January 2014. STUDY SELECTION: Studies that measured quality of life or participation outcomes among individuals who acquired a physical disability as a result of an earthquake injury were included, with no limits on research design. DATA EXTRACTION: The search yielded 961 potentially relevant articles after removal of duplicates. Of these, only 8 articles met the inclusion criteria. Studies were rated for quality using the Critical Appraisal Skills Programme (CASP) guidelines. DATA SYNTHESIS: A narrative synthesis was performed due to the heterogeneity of the included studies. RESULTS: Injured earthquake survivors in developing countries experience diminished participation and reduced quality of life. Small sample sizes and lack of uniformity in outcome measurement limit generalizability. No studies from developed countries were identified. CONCLUSION: To maximize our understanding of quality of life and participation in injured earthquake survivors, future research should consider both the functional consequences of the injury and the environmental impact of the earthquake. The research should be based on representative samples of the injured earthquake survivors and use validated condition-specific outcome measures that are clearly defined within the publications. In addition, research should include all countries that are affected by earthquakes.

"The final piece of the puzzle to fit in": an interpretative phenomenological analysis of the return to employment in New Zealand after spinal cord injury.

PURPOSE: Little is known about employment experience after spinal cord injury (SCI) because most research to date concentrates on employment predictors. We explored the experiences of people with SCI, and vocational rehabilitation (VR) professionals working for a VR programme, in pursuing a return to employment in New Zealand (NZ) post-SCI. METHODS: Twelve people with SCI (four employed, three job-seeking, five unemployed) and six VR professionals were interviewed, and the transcripts subjected to an Interpretative Phenomenological Analysis. RESULTS: The core meaning of employment post-SCI was to live a normal life. Work advantages were social connectedness, a sense of self-worth, earning a living, and being occupied. Employment was the zenith of rehabilitation but not the first priority post-SCI. Employment barriers and facilitators were congruent with those found in similar studies. The role of VR was to sow the seeds of return to employment and to partner with the SCI client. CONCLUSIONS: For persons employed pre-SCI, we posit that employment identity modification is part of the return to employment process, alongside a supportive social context and networks, and adapted work environments. VR professionals may facilitate return to employment through understanding and fostering the process of employment identity modification and supporting clients to find work opportunities congruent with employment identity.

Utilisation of patient perspective to validate clinical measures of outcome following spinal cord injury.

PURPOSE: The purpose of this article is to utilise the perspective of persons with a spinal cord injury (SCI), gained from focus groups, to validate recommended clinical measures of outcome. METHOD: Clinical measures of outcome as recommended by Wood-Dauphinee and the SCI Consensus Group were categorised using the World Health Organisation's International Classification of Functioning, Disability and Health (ICF). These were then cross-referenced to the problems of functioning identified by patients in 10 focus groups held in New Zealand as part of the International ICF Core Set project. The focus groups were performed separately for people in the post-acute situation and in the chronic situation to address different experiences since SCI. RESULTS: In the post-acute group, the recommended measures of functioning, the Functional Independence Measure (FIM), Hospital Anxiety and Depression Scale and Visual Analogue Scale for pain correlated well against the focus groups identification of problems of functioning. In the chronic group, the short-form Craig Handicap Assessment and Reporting Technique (sf-CHART), the SF-12 and the Life Satisfaction Questionnaire (LSQ) largely captured the problems of functioning identified. There were some categories that were common to both patient groups and were not changed by time since SCI. In addition, there were some problems of functioning identified by the patient groups that were not covered by the suggested measures. CONCLUSIONS: Utilisation of a battery of outcome measures based on a theoretical framework can quantify problems of functioning in the SCI population. Although the measures suggested by SCI Consensus Group largely capture the problems of functioning, other outcome measures have been shown to be more responsive to the changes in the SCI population and also incorporate more of the identified problems of functioning.