A randomized clinical trial for a self-guided sleep intervention following moderate-severe traumatic brain injury: Study protocol

BACKGROUND

Individuals with a history of moderate-severe traumatic brain injury (TBI) experience a significantly higher prevalence of insomnia compared to the general population. While individuals living with TBI have been shown to benefit from traditional insomnia interventions (e.g., face-to-face [F2F]), such as Cognitive Behavioral Therapy for Insomnia (CBTI), many barriers exist that limit access to F2F evidence-based treatments. Although computerized CBT-I (CCBT-I) is efficacious in terms of reducing insomnia symptoms, individuals with moderate-severe TBI may require support to engage in such treatment. Here we describe the rationale, design, and methods of a randomized controlled trial (RCT) assessing the efficacy of a guided CCBT-I program for reducing insomnia symptoms for participants with a history of moderate-severe TBI.

METHODS

This is an RCT of a guided CCBT-I intervention for individuals with a history of moderate-severe TBI and insomnia. The primary outcome is self-reported insomnia severity, pre- to post-intervention. Exploratory outcomes include changes in sleep misperception following CCBT-I and describing the nature of guidance needed by the Study Clinician during the intervention.

CONCLUSION

This study represents an innovative approach to facilitating broader engagement with an evidence-based online treatment for insomnia among those with a history of moderate-severe TBI. Findings will provide evidence for the level and nature of support needed to implement guided CCBT-I. Should findings be positive, this study would provide support for a strategy by which to deliver guided CCBT-I to individuals with a history of moderate-severe TBI.

Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury

STUDY OBJECTIVES

We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM.

METHODS

Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans.

RESULTS

Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively.

CONCLUSIONS

Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes.

CITATION

Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med. 2024;20(5):801-812.

Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury

OBJECTIVE

To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI).

METHOD

Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach.

RESULTS

Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support).

CONCLUSIONS

Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Identifying and Predicting Subgroups of Veterans With Mild Traumatic Brain Injury Based on Distinct Configurations of Postconcussive Symptom Endorsement: A Latent Class Analysis

OBJECTIVE

To identify distinct subgroups of veterans with mild traumatic brain injury (mTBI) based on configurations of postconcussive symptom (PCS) endorsement, and to examine predictors of subgroup membership.

SETTING

Outpatient Veterans Health Administration (VHA).

PARTICIPANTS

Veterans with clinician-confirmed mTBI who completed the Neurobehavioral Symptom Inventory (NSI), determined using the Comprehensive Traumatic Brain Injury Evaluation database. Individuals who tended to overreport symptoms were excluded via an embedded symptom validity scale.

DESIGN

Retrospective cohort study leveraging national VHA clinical data from 2012 to 2020. Latent class analysis (LCA) with a split-sample cross-validation procedure was used to identify subgroups of veterans. Multinomial logistic regression was used to examine predictors of subgroup membership.

MAIN MEASURES

Latent classes identified using NSI items.

RESULTS

The study included 72 252 eligible veterans, who were primarily White (73%) and male (94%). The LCA supported 7 distinct subgroups of veterans with mTBI, characterized by diverging patterns of risk for specific PCS across vestibular (eg, dizziness), somatosensory (eg, headache), cognitive (eg, forgetfulness), and mood domains (eg, anxiety). The most prevalent subgroup was Global (20.7%), followed by Cognitive-Mood (16.3%), Headache-Cognitive-Mood (H-C-M; 16.3%), Headache-Mood (14.2%), Anxiety (13.8%), Headache-Sleep (10.3%), and Minimal (8.5%). The Global class was used as the reference class for multinomial logistic regression because it was distinguished from others based on elevated risk for PCS across all domains. Female (vs male), Black (vs White), and Hispanic veterans (vs non-Hispanic) were less likely to be members of most subgroups characterized by lesser PCS endorsement relative to the Global class (excluding Headache-Mood).

CONCLUSION

The 7 distinct groups identified in this study distill heterogenous patterns of PCS endorsement into clinically actionable phenotypes that can be used to tailor clinical management of veterans with mTBI. Findings reveal empirical support for potential racial, ethnic, and sex-based disparities in PCS among veterans, informing efforts aimed at promoting equitable recovery from mTBI in this population.

Unmet Need for Outpatient Occupational Therapy Services Among Veterans With Mild Traumatic Brain Injury in the Veterans Health Administration: The Role of Facility Characteristics

OBJECTIVE

To investigate whether participation restrictions, an indicator of need for occupational therapy (OT), was associated with outpatient OT utilization in the Veterans Health Administration (VHA) among Veterans with mild traumatic brain injury (mTBI), and whether this relation differs by facility characteristics.

DESIGN

In a secondary analysis of national VHA data, we used modified Poisson regression to model OT utilization (yes/no) as a function of participation restrictions (Mayo-Portland Adaptability Inventory Participation Index [M2PI]), facility characteristics, and covariates. Facility characteristics included complexity, geographic region, and self-reported access to specialty care. Covariates included prior OT utilization, sociodemographic factors, injury characteristics, and spatial access (eg, drive time). Interactions estimated whether the relation between participation restrictions and OT utilization differed across facility characteristics.

SETTING

Outpatient setting in the VHA.

PARTICIPANTS

8684 Veterans with a clinician-confirmed mTBI who received outpatient VHA care between 2012 and 2020 (N=8684).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

OT utilization was measured within a year of M2PI administration using VHA administrative data.

RESULTS

Many Veterans who did not receive OT reported participation limitations, indicating unmet need for OT (eg, 67% with leisure restrictions). Participation restrictions were associated with increased likelihood of receiving OT (risk ratio [RR]=1.01; 95% confidence interval [CI]=1.006-1.019), suggesting a tendency for Veterans' OT-related needs to be satisfied. However, interactions indicated that this was not the case among Veterans receiving care in lower complexity facilities, and those in the South. Veterans with longer drive times were less likely to receive OT (RR=0.82; 95% CI=0.744-0.904).

CONCLUSIONS

Participation restrictions were associated with OT utilization, yet many Veterans with mTBI who may have benefited did not receive such care. Specific barriers to accessing OT (eg, OT practitioner supply) should be investigated. Novel care models can ensure access to OT services among Veterans seeking care at less-resourced and/or geographically distant VHA facilities.

Predicting Receipt and Types of Occupational Therapy Services for Patients with Arousal Deficits in the Neuro Critical Care Unit

Occupational therapy has been identified as a required service in the neuro critical care unit (NCCU), however who receives occupational therapy services and what services they receive are not well understood. We sought to determine if arousal deficits impacted patients' likelihood to receive an occupational therapy evaluation or specific types of occupational therapy interventions in the NCCU. When compared to patients without arousal deficits, patients who were experiencing agitation or light sedation, but not deep sedation, were more likely to receive occupational therapy interventions in the therapeutic activities category. Arousal deficits were not associated with receipt of occupational therapy services or occupational therapy interventions in the self-care or therapeutic exercise categories. Determining predictors of occupational therapy services will help ensure the timely delivery of services by improving the allocation of resources and identifying potential gaps in care.

Suicide risk among veterans using VHA justice-involved services: a latent class analysis

BACKGROUND

Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited.

METHODS

We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018.

RESULTS

A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide.

CONCLUSIONS

Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.

Learning Health Systems Research Competencies: A Survey of the Rehabilitation Research Community

OBJECTIVE

The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources.

METHODS

The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements.

RESULTS

Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%).

CONCLUSION

Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training.

IMPACT

Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Are Social Determinants of Health Associated With Onset of Rehabilitation Services in Patients Hospitalized for Traumatic Brain Injury?

OBJECTIVE

To examine the impact of community-level social determinants of health (SDoH) on the onset of occupational therapy (OT) and physical therapy (PT) services among individuals hospitalized for traumatic brain injury (TBI).

SETTING

14 acute care hospitals in the state of Colorado.

PARTICIPANTS

We studied 5825 adults with TBI.

DESIGN

In a secondary analysis of de-identified electronic health record data, we performed multivariable logistic and linear regressions to calculate odds ratios (ORs) and 95% CIs for the likelihood of receiving services and duration to initiation of services among those who received them.

MAIN MEASURES

Community-level SDoH, receipt of rehabilitation services, and onset of rehabilitation services.

RESULTS

Multivariable logistic and linear regressions revealed that those in top quartiles for community income were associated with duration to OT services, ranging from OR = 0.33 [05% CI, 0.07, 0.60] for quartile 2 to 0.76 [0.44, 1.08] for quartile 4 compared with those with the lowest quartile. Only the top quartile differed significantly for duration to PT services (0.63 [0.28, 0.98]). Relative to those with below the median community percentage of high school degree, those with above the median were associated with duration to PT services only (-0.32 [-0.60, -0.04]). Neither community percentage with bachelor's degree nor rural-urban designation was associated with duration to either therapy service.

CONCLUSION

Further research is needed to determine whether our SDoH variables were too diffuse to capture individual experiences and impacts on care or whether community-level education and income, and rurality, truly do not influence time to therapy for patients hospitalized with TBI. Other, individual-level variables, such as age, comorbidity burden, and TBI severity, demonstrated clear relationships with therapy onset. These findings may help therapists evaluate and standardize equitable access to timely rehabilitation services.

Research Letter: Traumatic Brain Injury Among Veterans Accessing VA Justice-Related Services

OBJECTIVE

Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (ie, justice-involved Veterans) remains limited. The sequelae of TBI can impact justice-involved Veterans' engagement in Department of Veterans Affairs (VA) justice-related services (ie, Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting psychosocial functioning. As such, further understanding of TBI risk among justice-involved Veterans has the potential to inform the need for tailored screening and interventional efforts within VA justice-related service settings. We sought to better understand relative risk for TBI diagnosis among male and female Veteran recipients and nonrecipients of VA justice-related services.

SETTING

Electronic medical record data for Veterans accessing VA services from 2005 to 2018.

PARTICIPANTS

1517 447 (12.48% justice-involved) male and 126 237 (8.89% justice-involved) female Veterans.

DESIGN

A cross-sectional examination of national VA electronic medical record data. Sex-stratified analyses were conducted to examine relative risk of TBI diagnosis based on use of VA justice-related services.

MAIN MEASURES

Documented TBI diagnosis was the main outcome. Covariates included VA service use, age, race, and ethnicity.

RESULTS

Both male and female Veterans using VA justice-related services were more likely to have a documented TBI diagnosis in their electronic VA medical record. Associations were attenuated, yet maintained significance, in all adjusted and sensitivity models.

CONCLUSIONS

Given potential risk for TBI, enhancing and tailoring care for justice-involved Veterans may be critical to facilitating rehabilitation and reducing recidivism. Examination of existing services within justice-related settings and methods of augmenting care is an important next step.

Morally injurious combat events as an indirect risk factor for postconcussive symptoms among veterans: The mediating role of posttraumatic stress

OBJECTIVE

Psychosocial factors, including combat-related distress (e.g., posttraumatic stress disorder [PTSD]), contribute to postconcussive symptoms (PCS) among veterans with mild traumatic brain injury (mTBI). However, research on risk factors for PCS has focused solely on life-threatening combat experiences, neglecting the morally injurious dimension of combat-related trauma and associated implications for treatment. Morally injurious events (MIEs) are associated with PTSD symptoms among veterans, a robust risk factor of PCS. Nonetheless, the interplay between MIEs, PTSD symptoms, and PCS remains poorly understood. We sought to investigate MIEs as an indirect risk factor for PCS among Veterans with mTBI.

METHOD

This cross-sectional study of 145 veterans with mTBI used path analysis to investigate whether PTSD symptoms mediated the relationship between MIEs (transgressions and betrayals) and PCS (mood-behavioral, vestibular-sensory, and cognitive domains) among 145 veterans with mTBI. We used the Moral Injury Event Scale, PTSD Checklist-Civilian Version, and Neurobehavioral Symptom Inventory to measure MIEs, PTSD, and PCS, respectively.

RESULTS

Perceived transgressions were indirectly associated with mood-behavioral (β = .21, p = .005), vestibular-sensory (β = .17, p = .005), and cognitive PCS (β = .20, p = .005), as mediated by PTSD. Greater transgressions were associated with more severe PTSD (β = .27, p = .003), and greater PTSD was associated with more severe mood-behavioral (β = .79, p < .001), vestibular-sensory (β = .64, p < .001), and cognitive PCS (β = .73, p < .001). Betrayals were not indirectly associated with PCS.

CONCLUSIONS

Findings offer preliminary support for responses to MIEs being a modifiable risk factor for PCS among veterans. Interventions designed to foster veterans' recovery by targeting the unique emotions and beliefs associated with MIEs may be indicated. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The unique association of posttraumatic stress disorder with hypertension among veterans: A replication of Kibler et al. (2009) using Bayesian estimation and data from the United States-Veteran Microbiome Project

OBJECTIVE

Kibler et al. (2009) reported that hypertension was related to PTSD independent of depression. These two conditions have significant diagnostic overlap. The present study sought to conceptually replicate this work with a veteran sample, using Bayesian estimation to directly update past results, as well as examine symptom severity scores in relation to hypertension.

METHOD

This was a secondary analysis of data obtained from the United States-Veteran Microbiome Project. Lifetime diagnoses of PTSD and major depressive disorder (MDD) were obtained from a structured clinical interview and hypertension diagnoses were extracted from electronic medical records. PTSD and depressive symptom severity were obtained from self-report measures. Logistic regressions with Bayesian estimation were used to estimate the associations between hypertension and (a) psychiatric diagnostic history and (b) symptom severity scores.

RESULTS

Compared with veterans without lifetime diagnoses of either disorder, the PTSD-only group was estimated to have a 29% increase in hypertension risk, and the PTSD + MDD group was estimated to have a 66% increase in hypertension risk. Additionally, higher levels of PTSD symptom severity were associated with a higher risk of hypertension.

CONCLUSION

PTSD diagnosis and symptom severity are uniquely associated with hypertension, independent of MDD or depressive symptom severity. These results support previous findings that PTSD might be a modifiable risk factor for the prevention and treatment of hypertension. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations between deployment experiences, safety-related beliefs, and firearm ownership among women Veterans

INTRODUCTION

Among women Veterans, firearms are the leading suicide means. This has prompted efforts to elucidate factors associated with women Veterans' firearm ownership. This cross-sectional study examined if deployment experiences were associated with firearm ownership among women Veterans and if safety-related beliefs mediated these associations.

METHODS

492 previously deployed post-9/11 women Veterans participated in a national survey that included the Deployment Risk and Resilience Inventory-2, subscales of the Posttraumatic Cognitions Inventory and Posttraumatic Maladaptive Beliefs Scale, and firearm ownership questions. Path analysis was used.

RESULTS

Perceived threat during deployment was associated with firearm ownership, irrespective of safety-related beliefs. Indirect effects did not support that safety-related beliefs mediated relations between deployment experiences and firearm ownership. The other deployment experiences (sexual harassment, sexual assault, general harassment, combat experiences) were not indirectly associated with firearm ownership, nor were safety-related beliefs (negative cognitions about the world, threat of harm, beliefs about others' reliability and trustworthiness) directly associated with firearm ownership. In an exploratory serial mediation analysis, perceived threat during deployment mediated the association between combat experiences and firearm ownership. In a sensitivity analysis examining firearm acquisition following military service, results were similar, except the indirect effect of combat experiences upon firearm acquisition through perceived threat was not significant.

CONCLUSION

Post-9/11 women Veterans' firearm acquisition and ownership may relate to specific deployment experiences, such as perceived threat; however, longitudinal studies are needed to fully ascertain this. Efforts to address firearm access among post-9/11 women Veterans may benefit from assessing heightened sense of danger during deployment.

A practical guide to random-effects Bayesian meta-analyses with application to the psychological trauma and suicide literature

OBJECTIVE

Bayesian meta-analyses offer several advantages over traditional approaches, including improved accuracy when using a small number of studies and enhanced estimation of heterogeneity. However, psychological trauma research has yet to see widespread adoption of these statistical methods, potentially due to researchers' unfamiliarity with the processes involved. The purpose of this article is to provide a practical tutorial for conducting random-effects Bayesian meta-analyses.

METHOD

Explanations and recommendations are provided for completing the primary steps of a Bayesian meta-analysis, ranging from model specification to interpretation of results. Furthermore, an illustrative example is used to demonstrate the application of each step. In the example, results are synthesized from six studies included in a previously published systematic review (Holliday et al., 2020), with a combined sample size of 21,244,109, examining the association between posttraumatic stress disorder and risk of suicide in veterans and military personnel.

RESULTS

The posterior distributions for each model estimate, such as the pooled effect size and the heterogeneity parameter, are discussed and interpreted with regard to the probability of increased suicide risk.

CONCLUSIONS

Our hope is that this tutorial, along with the provided data and code, facilitate the use of Bayesian meta-analyses in the study of psychological trauma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A latent class analysis to identify subgroups of VHA using homeless veterans at greater risk for suicide mortality

BACKGROUND

Homeless Veterans are at substantially elevated risk for suicide mortality; however, understanding of drivers of suicide in this population remains limited.

METHOD

Building upon prior work, we conducted a retrospective chart review, comprised of a latent class analysis of 724,752 Veterans with use of Veterans Health Administration (VHA) homeless services 2005-2018.

RESULTS

A five-model class membership solution was identified. Among these classes, risk for suicide mortality was greatest among Veterans with the highest psychiatric burden and high VHA service use. Those experiencing moderate psychiatric burden or primarily experiencing substance use disorders also experienced elevated risk for suicide mortality relative to those with low burden and service use.

LIMITATIONS

Models were specific to Veterans accessing VHA homeless services and may not generalize to those not using such services outside VHA care.

CONCLUSIONS

Continued research and programing remain necessary to determine how to address mental health conditions and engage homeless Veterans in services to facilitate suicide prevention.

Post-concussive symptoms mediate the relationship between sleep problems and participation restrictions among veterans with mild traumatic brain injury

Background

Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.

Materials and Methods

This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: (1) sleep problems and three latent indicators of post-concussive symptoms [vestibular-sensory (e.g., headache)]; mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, (2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).

Results

87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = -0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).

Discussion

Findings suggest that evidence-based sleep treatment should occupy a prominent role in the rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation vs. productivity, informing individualized rehabilitative care for Veterans with mTBI.

Participation Mediates the Relationship Between Postconcussive Symptoms and Suicidal Ideation Among Veterans

IMPORTANCE

Veterans with mild traumatic brain injury (mTBI) and associated symptoms are at risk for suicide. Postconcussive symptoms (PCS) may heighten risk for suicidal thoughts by limiting veterans' participation.

OBJECTIVE

To investigate whether participation mediates the relationship between PCS and suicidal ideation.

DESIGN

Cross-sectional, exploratory design. Structural equation models were used to investigate whether participation mediated the relationship between PCS and suicidal ideation.

SETTING

Community.

PARTICIPANTS

Veterans with mTBI (N = 145).

OUTCOMES AND MEASURES

The Ohio State University TBI Identification Method was used to establish mTBI diagnosis. We identified latent variables for PCS and participation using the Neurobehavioral Symptom Inventory and select domains of the Medical Outcomes Study Short Form-36, respectively. We used the Beck Scale for Suicide Ideation to measure the presence of suicidal ideation.

RESULTS

Participation mediated the relationship between PCS and the presence of suicidal ideation (odds ratio [OR] = 1.09, p = .011). More severe PCS were associated with lesser participation (β = -.86, p < .001); greater participation was associated with lower odds of suicidal ideation (OR = 0.92, p = .007).

CONCLUSIONS AND RELEVANCE

PCS may heighten risk for suicidal thoughts among veterans by limiting successful participation, a primary target of occupational therapy intervention. Thus, the results suggest that occupational therapy practitioners can play a substantial role in suicide prevention services for veterans with mTBI. Preventive services could mitigate suicide risk among veterans with mTBI by enabling sustained engagement in meaningful and health-promoting activity (e.g., reasons for living) and targeting PCS. What This Article Adds: Researchers have proposed that occupational therapy practitioners can help prevent veteran suicide by supporting their engagement in meaningful, health-promoting activity and by targeting suicide risk factors within their scope of practice. To the best of our knowledge, this is the first study to offer empirical support for such proposed suicide prevention efforts. Although additional research is needed, these results are promising and highlight a distinct role for occupational therapy in suicide prevention.

Follow-Up Analyses From a Wait-List Controlled Trial of Occupational Therapist-Delivered Cognitive-Behavioral Therapy for Insomnia Among Veterans With Chronic Insomnia

IMPORTANCE

Veterans often experience chronic insomnia, and professionals capable of delivering effective interventions to address this problem are lacking.

OBJECTIVE

To evaluate the efficacy of the Restoring Effective Sleep Tranquility (REST) program, an occupational therapist-led cognitive-behavioral therapy for insomnia (CBT-I) intervention to treat sleep problems among post- 9/11 veterans.

DESIGN

Wait-list controlled trial with 3-mo follow-up.

SETTING

Community-based veteran support program in a Mountain West university.

PARTICIPANTS

Fifteen post-9/11 veterans with sleep disturbances who were assigned to either the REST intervention or a wait-list control group. Outcomes and Measures: Sleep-related, health-related, and participation-related patient-reported outcomes (PROs) and daily sleep diary variables.

RESULTS

Wait-list controlled trial benefits included improved sleep-related (e.g., sleep disturbance), health-related (e.g., depression), and participation-related (e.g., meaningful activity) PROs. Findings were confirmed after participants in both the intervention and the control groups (n = 13) received the REST intervention, including improved daily sleep diary outcomes (e.g., sleep efficiency). All gains were maintained at 3 mo.

CONCLUSIONS AND RELEVANCE

Occupational therapy practitioners with advanced training in CBT-I have the potential to safely deliver an effective CBT-I intervention to veterans with sleep disturbances in a community-based setting. What This Article Adds: Occupational therapy practitioners with sleep-related education and training can positively affect the well-being of their clients through improving sleep participation.

Mobility status and acute care physical therapy utilization: The Moderating roles of age, significant others, and insurance type

OBJECTIVE

To investigate whether a direct measure of need for PT, mobility status, was associated with acute care PT utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

In a secondary analysis of electronic health records data, we estimated logistic regression models to determine whether mobility status was associated with acute care PT utilization. Interactions between mobility and both sociodemographic factors (sex; age; significant other; minority status) and insurance type were included to investigate whether the relationship between mobility and PT utilization varied across patient characteristics.

SETTING

Five regional hospitals from one health system.

PARTICIPANTS

60,459 adults admitted between 2014 and 2018 who received a PT evaluation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Received acute care PT; Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" measure of mobility.

RESULTS

Half of patients who received a PT evaluation received subsequent treatment. Patients with mobility limitations were more likely to receive PT. Interaction terms indicated that among patients with mobility limitations, those who 1) were younger; 2) had significant others; and 3) had private insurance (vs. public) were more likely to receive PT. Among patients with greater mobility status, older patients and those without a significant other were more likely to receive PT.

CONCLUSIONS

The relationship between acute care PT need and utilization differed across sociodemographic factors and insurance type. We offer potential explanations for these findings to guide studies targeting equitable distribution of beneficial PT services.

Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

IMPORTANCE

Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied.

OBJECTIVE

To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type.

PARTICIPANTS

A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation.

INTERVENTION

None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity.

RESULTS

Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance.

CONCLUSIONS AND RELEVANCE

Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

Activities of Daily Living Performance and Acute Care Occupational Therapy Utilization: Moderating Factors

IMPORTANCE

Hospitalized patients who have difficulty performing activities of daily living (ADLs) benefit from occupational therapy services; however, disparities in access to such services are understudied.

OBJECTIVE

To investigate whether need (i.e., limited ADL performance) predicts acute care occupational therapy utilization and whether this relationship differs across sociodemographic factors and insurance type.

DESIGN

A secondary analysis of electronic health records data. Logistic regression models were specified to determine whether ADL performance predicted use of occupational therapy treatment. Interactions were included to investigate whether the relationship between ADL performance and occupational therapy utilization varied across sociodemographic factors (e.g., age) and insurance type.

PARTICIPANTS

A total of 56,022 adults admitted to five regional hospitals between 2014 and 2018 who received an occupational therapy evaluation.

INTERVENTION

None. Outcomes and Measures: Occupational therapy service utilization, Activity Measure for Post-Acute Care "6-Clicks" measure of daily activity.

RESULTS

Forty-four percent of the patients evaluated for occupational therapy received treatment. Patients with lower ADL performance were more likely to receive occupational therapy treatment; however, interaction terms indicated that, among patients with low ADL performance, those who were younger, were White and non-Hispanic, had significant others, and had private insurance (vs. public) were more likely to receive treatment. These differences were smaller among patients with greater ADL performance.

CONCLUSIONS AND RELEVANCE

Greater need was positively associated with receiving occupational therapy services, but this relationship was moderated by age, minoritized status, significant other status, and insurance type. The findings provide direction for exploring determinants of disparities in occupational therapy utilization. What This Article Adds: Acute care occupational therapy utilization is driven partly by patient need, but potential disparities in access to beneficial services may exist across sociodemographic characteristics and insurance type. Identifying potential determinants of disparities in acute care occupational therapy utilization is the first step in developing strategies to reduce barriers for those in need.

Predicting Community Discharge for Occupational Therapy Recipients in the Neurological Critical Care Unit

IMPORTANCE

Occupational therapy in the neurological critical care unit (NCCU) may enable safe community discharge by restoring functional ability. However, the influence of patient characteristics and NCCU occupational therapy on discharge disposition is largely unknown.

OBJECTIVE

To examine how patient factors and receipt of occupational therapy predict discharge disposition for NCCU patients.

DESIGN

Retrospective cross-sectional cohort study of electronic health records data from adults admitted to the NCCU between May 2013 and September 30, 2015.

SETTING

NCCU in a large urban academic hospital.

PARTICIPANTS

Adults age 18 yr or older (N = 1,134) admitted to the NCCU. Outcomes and Measures: Using logistic regression with discharge disposition as the dependent variable, we entered sex, age, length of stay (LOS), baseline Glasgow Coma Scale score, Elixhauser Comorbidity Index, and receipt of occupational therapy services as predictor variables.

RESULTS

Of NCCU patients, 39% received occupational therapy. Younger age, shorter LOS, lower comorbidity burden, and not receiving occupational therapy services increased the likelihood of discharge to the community. Men who received occupational therapy were less likely to be discharged to the community than men who did not receive occupational therapy. As age increased, differences in the probability of community discharge decreased between recipients and nonrecipients of occupational therapy services.

CONCLUSIONS AND RELEVANCE

Our results suggest that patients receiving occupational therapy services in the NCCU may have a lower likelihood of community discharge. However, these findings may result from therapist's consideration of the safest discharge location to ensure the greatest balance between independence and support. What This Article Adds: This study's findings suggest that receipt of occupational therapy in the NCCU is associated with higher likelihood for noncommunity discharge (i.e., to inpatient rehabilitation, skilled nursing, or long-term care). However, activity limitations and comorbidity burden may be greater for recipients of occupational therapy, and these NCCU patients are presumably less prepared for community discharge.

Learning Health Systems Can Promote and Sustain High-Value Occupational Therapy

In the current policy context, the occupational therapy profession must act to promote and sustain high-value care. Stakeholders have delineated efforts, such as defining and measuring high-quality care processes or promoting the adoption of evidence into practice, that can enhance the value of occupational therapy services. There is a growing recognition, however, that low-value care is the product of deficiencies within health care systems and is therefore most amenable to system-level solutions. To date, the specific nature of system-level changes capable of identifying and rectifying low-value occupational therapy has yet to be elucidated. In this "The Issue Is. . ." column, we introduce occupational therapy to the Learning Health System concept and its essential functions. Moreover, we discuss action steps for occupational therapy stakeholders to lay the foundation for Learning Health Systems in their own professional contexts. What This Article Adds: This article is the first to outline concrete action steps needed to transform occupational therapy practice contexts into Learning Health Systems. Such a transformation would represent a system-level change capable of fostering the delivery of high-value occupational therapy services to clients in a variety of practice settings.

Change in Activity Performance Mediates the Relationship between Occupational Therapy Utilization and Discharge Disposition among Adults with Traumatic Brain Injuries

A retrospective cross-sectional study was conducted on 435 adults with TBI who received occupational therapy services in an acute care trauma center hospital. Outcome measures were (1) occupational therapy utilization based on billed minutes of occupational therapy evaluation and treatment (low vs. high); (2) Activity Measure for Post-Acute Care (AM-PAC) "6-Clicks" to assess activities of daily living level of assistance; and (3) Discharge disposition (community vs. institution). Community discharge included home and supported living facilities. Institutional discharge involved long term care, rehabilitation facility, short term hospital, and skilled nursing facility. Results indicated that change in ADL performance, between admission and discharge, partially mediated the relationship between occupational therapy utilization and community discharge (OR= 0.80, p = .003). High occupational therapy utilization (vs. low) was associated with greater change in ADL performance (β = 0.39, p < .001). Greater change in ADL performance was associated with lower odds of community discharge (OR= 0.96, p <.001). Independent of change in ADL performance, higher occupational therapy utilization was associated with significantly lower odds for community discharge (OR = 0.57, p = 0.023). In conclusion, patients who received more occupational therapy were less likely to be community discharged, as mediated by change in ADL performance. This result can provide direction for future research exploring acute care occupational therapy utilization and discharge disposition.

Met and unmet rehabilitative needs among pediatric patients with moderate to severe TBI

OBJECTIVE

Estimate the probability of met and unmet post-acute rehabilitative needs among pediatric patients with moderate to severe traumatic brain injury (TBI).

PARTICIPANTS

One hundred and thirty children who received acute and post-acute rehabilitative services at a hospital for children.

METHODS

Prospective, observational study. Recommended service needs (1. Medical, 2. Psychological, 3. Cognitive/Educational, 4. Medically Based Therapies, 5. Community/Caregiver/Family Support) were collected at discharge and 1, 6, 12, and 18 months post-injury. Probabilities were estimated using nonlinear logistic regression models. The impact of age at discharge was also assessed.

RESULTS

Over time, the estimated probability of need for Medical, Medically Based Therapies, and Cognitive/Educational services were consistently high. Whereas unmet need for Medical and Medically Based Therapies were low, unmet need for Cognitive/Educational services were relatively high. Need for Psychological and Community/Caregiver/Family Support services increased in the months post-discharge, as did the probability of unmet need. Older age at discharge was associated with need for Psychological and Community/Caregiver Family Support services.

CONCLUSIONS

Findings support the long-term monitoring of need for Psychological and Community/Caregiver/Family Support services among children with moderate to severe TBI. Future research to explore the etiology of unmet needs is warranted.

Evaluating the strength of evidence for statistically significant rehabilitation treatment effects

BACKGROUND

Relying solely on null hypothesis significance testing to investigate rehabilitation interventions may result in researchers erroneously concluding the presence of a treatment effect.

OBJECTIVE

We sought to quantify the strength of evidence in favour of rehabilitation treatment effects by calculating Bayes factors (BF10s) for significant findings. Additionally, we sought to examine associations between BF10s, p-values, and Cohen's d effect sizes.

METHODS

We searched the Cochrane Database of Systematic Reviews for meta-analyses with "rehabilitation" as a keyword that evaluated a rehabilitation intervention. We extracted means, standard deviations, and sample sizes for treatment and comparison groups from individual findings within 175 meta-analyses. Investigators independently classified the interventions according to the Rehabilitation Treatment Specification System. We calculated t-statistics, p-values, effect sizes, and BF10s for each finding. We isolated statistically significant findings (p ≤ 0.05); applied evidential categories to BF10s, p-values, and effect sizes; and examined relationships descriptively.

RESULTS

We analysed 1,935 rehabilitation findings. Across intervention types, 25% of significant findings offered only anecdotal evidence in favour of a treatment effect; only 48% indicated strong evidence. This pattern persisted within intervention types and when conducting robustness analyses. Smaller p-values and larger effect sizes were associated with stronger evidence in favour of a treatment effect. However, a notable portion of findings with p-value 0.01 to 0.05 (63%) or a large effect size (18%) offered anecdotal evidence in favour of an effect.

CONCLUSIONS

For a substantial portion of statistically significant rehabilitation findings, the data neither support nor refute the presence of a treatment effect. This was the case among a notable portion of large treatment effects and for most findings with p-value > 0.01. Rehabilitation evidence would be improved by researchers adopting more conservative levels of significance, complementing the use of null hypothesis significance testing with Bayesian techniques and reporting effect sizes.

Combat exposure undermines student veterans' achievement of a meaningful life through its association with health-related symptoms: A longitudinal study

Objective: To understand whether symptoms of health conditions explain the negative association between combat exposure and student Veterans' achievement of a meaningful life. Participants: 153 combat Veterans enrolled in college between November 2013 and April 2018. Methods: Through an online survey, participants reported combat exposure, health status (symptoms of conditions such as depression), and aspects of a meaningful life (belonging, self-understanding, and doing) at two time points. Path analysis was used to explore whether baseline health status mediated the relationship between combat exposure and belonging, self-understanding, and doing at follow-up. Results: Indirect effects indicated that the negative influence of combat on student Veterans' sense of belonging, self-understanding, and doing at follow-up was mediated by poor health at baseline. Conclusions: Combat exposure may contribute to the development of health conditions, which in turn limit student Veterans' experience of three aspects of a meaningful life: a sense of belonging, self-understanding, and doing.

Protective and Health-Related Factors Contributing to Resilience Among Student Veterans: A Classification Approach

IMPORTANCE

Occupational therapists can foster student veterans' resilience, but targets for intervention must be developed.

OBJECTIVE

To explain factors influencing student veterans' successful adaptation to past combat exposure, we hypothesized that participants with high life meaning would have greater levels of protective factors and lower levels of health conditions than those with low life meaning.

DESIGN

Longitudinal panel study with two measurements. Participants were classified by level of combat exposure (high-low) and life meaning (high-low) at follow-up, yielding four possible classifications (e.g., resilient group: high combat exposure, high life meaning). Linear mixed models were fit to obtain adjusted means of protective factors and health conditions for each classification; independent-samples t tests were used to examine differences between classifications.

SETTING

Community.

PARTICIPANTS

Convenience sample of 153 combat-exposed student veterans.

OUTCOMES AND MEASURES

Psychometrically sound measures of combat exposure, life meaning, protective factors (social and instructor autonomy support, coping ability, academic self-efficacy, social-community participation, and meaningful activity), and health conditions (posttraumatic stress [PTSD], depression, somatic symptoms).

RESULTS

Groups with high life meaning at follow-up in response to both levels of combat exposure reported greater meaningful activity and coping ability and fewer depressive symptoms. Participants with high life meaning in response to low combat exposure had greater social support and fewer somatic symptoms; participants with high life meaning in response to high combat exposure had lower PTSD.

CONCLUSIONS AND RELEVANCE

Occupational therapists may foster student veterans' resilience by promoting meaningful activity, social support, and coping ability while managing symptoms of health conditions.

WHAT THIS ARTICLE ADDS

To the best of our knowledge, this study is the first to offer empirical support for potential targets of occupational therapy intervention that address student veterans' successful adaptation to combat exposure. Findings suggest that researchers should develop and test interventions that facilitate successful engagement in meaningful and shared activities and that occupational therapists should work within multidisciplinary teams to bolster coping ability and manage symptoms of combat-related health conditions.

Factors distinguishing veterans participating in supported education services from veterans on campus: Evidence supporting modifiable intervention targets

OBJECTIVE

The purpose of this study was to identify specific and modifiable supported education (SEd) service needs for the veteran population. To do so, we compared veterans participating in SEd services to other veterans on campus with respect to service-related challenges, community reintegration, and academic-related challenges. Identifying independent factors that distinguish veterans receiving SEd services from other veterans on campus may help operationalize interventions that target the unique challenges in this vulnerable population.

METHOD

This study used an exploratory cross-sectional design. We used logistic regression on 410 veterans attending college. Models tested whether sociodemographic characteristics (e.g., age), service-related challenges (e.g., combat exposure), academic-related challenges (e.g., academic self-efficacy), and aspects of community reintegration (e.g., employment status) distinguished veterans receiving SEd services (n = 94) from veterans on campus (n = 316).

RESULTS

Veterans who reported (a) more severe combat exposure, (b) more severe posttraumatic stress disorder (PTSD) symptoms, (c) service-related mild traumatic brain injury (mTBI), (d) lower levels of academic self-efficacy, and (e) no paid employment were more likely to participate in SEd services.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This study established several factors that distinguished veterans receiving SEd services from veterans on campus. Findings indicate that SEd education services for veterans should: (a) apply principles of trauma-informed care, (b) mitigate the influence of PTSD and/or mTBI upon academic success and community reintegration, (c) promote academic self-efficacy, and (d) integrate principles of supported employment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Participation Is Associated With Well-Being Among Community-Based Veterans: An Investigation of Coping Ability, Meaningful Activity, and Social Support as Mediating Mechanisms

IMPORTANCE

Occupational therapy practitioners can use therapeutic activity to promote veterans' well-being, but the mechanisms through which participation promotes well-being are poorly understood.

OBJECTIVE

To examine whether coping ability, meaningful activity, and social support mediate the relationship between participation and two indicators of veterans' overall well-being: life meaning (psychological well-being) and life satisfaction (subjective well-being).

DESIGN

Explanatory cross-sectional design. We used two multiple mediation models to test whether coping ability, meaningful activity, and social support explained the relationship between participation and both life meaning and life satisfaction. Models were adjusted for demographic characteristics and service-related health conditions (e.g., posttraumatic stress disorder).

SETTING

Community.

PARTICIPANTS

Three hundred eighty-nine community-based veterans attending college.

INTERVENTION

None.

OUTCOMES AND MEASURES

Measures of participation, coping ability, meaningful activity, social support, life meaning, life satisfaction, and service-related health conditions.

RESULTS

Meaningfulness of activity partially explained the relationship between participation and both psychological well-being (B = 0.16, standard error [SE] = 0.04, 99% confidence interval [CI] [0.07, 0.27]) and subjective well-being (B = 0.14, SE = 0.03, 99% CI [0.07, 0.24]). Social support partially explained the relationship between participation and subjective well-being (B = 0.05, SE = 0.02, 99% CI [0.01, 0.11]). These findings persisted when symptoms of service-related health conditions were accounted for.

CONCLUSIONS AND RELEVANCE

Veterans' participation is associated with a greater sense of meaningful activity and social support, which in turn promotes psychological and subjective well-being. Occupational therapy practitioners may promote veterans' well-being by supporting engagement in activities that elicit meaning and enable social interaction, although further study is needed.

WHAT THIS ARTICLE ADDS

This is among the first studies to test mechanisms underlying the relationship between veterans' engagement in activities and their overall well-being. Results may inform treatment theories for activity-based interventions in the veteran population. For example, results indicate that occupational therapy interventions that facilitate engagement in meaningful and shared activities could be developed to promote veterans' well-being.

Risk and recovery among high school athletes who sustained at least one sports-related concussion

Aim:

Evidence of factors explaining sports-related concussion (SRC) risk and recovery among high school athletes remains inconclusive.

Materials & methods:

Prospective study of a real-world sample of high school athletes (n = 77) who sustained ≤1 SRC. Among those with multiple SRCs, recovery time between events was investigated. To investigate concussion risk, baseline characteristics of athletes with a single versus multiple SRC(s) were compared.

Results:

Recovery time did not differ across events. There were no differences between those with a single versus multiple SRCs.

Conclusion:

Recovery time between initial and subsequent concussive events did not differ, suggesting that prior concussion may not prolong recovery. Baseline characteristics did not explain heightened concussion risk. Investigation of these relationships using more representative samples is needed.

Evidence that prior concussions and pre-injury symptoms explain sports-related concussion (SRC) risk and recovery among high school (HS) athletes remains inconclusive. This may be due to studies investigating HS athletes in medical settings. These athletes may experience more severe SRC, and therefore may not represent risk and recovery in real-world settings. We used a real-world sample of HS athletes to investigate whether prior concussion prolongs recovery for subsequent concussive events. To investigate heightened risk for concussion during the study period, we also examined differences between athletes who sustained a single versus multiple SRC during the study period. There were no differences between those with single versus multiple SRC(s). Based on our real-world sample of HS athletes, recovery time across concussive events during the study period did not differ, suggesting that a prior concussion may not prolong recovery.

Novel Effect Size Interpretation Guidelines and an Evaluation of Statistical Power in Rehabilitation Research

OBJECTIVE

First, to establish empirically-based effect size interpretation guidelines for rehabilitation treatment effects. Second, to evaluate statistical power in rehabilitation research.

DATA SOURCES

The Cochrane Database of Systematic Reviews was searched through June 2019.

STUDY SELECTION

Meta-analyses included in the Cochrane Database of Systematic Reviews with "rehabilitation" as a keyword and clearly evaluated a rehabilitation intervention.

DATA EXTRACTION

We extracted Cohen's d effect sizes and associated sample sizes for treatment and comparison groups. Two independent investigators classified the interventions into 4 categories using the Rehabilitation Treatment Specification System. The 25th, 50th, and 75th percentile values within the effect size distribution were used to establish interpretation guidelines for small, medium, and large effects, respectively. A priori power analyses established sample sizes needed to detect the empirically-based values for small, medium, and large effects. Post-hoc power analyses using median sample sizes revealed whether the "typical" rehabilitation study was sufficiently powered to detect the empirically-based values. Post hoc power analyses established the statistical power of each test based on the sample size and reported effect size.

DATA SYNTHESIS

We analyzed 3381 effect sizes extracted from 99 meta-analyses. Interpretation guidelines for small effects ranged from 0.08 to 0.15; medium effects ranged from 0.19 to 0.36; and large effects ranged from 0.41 to 0.67. We present sample sizes needed to detect these values based on a priori power analyses. Post hoc power analyses revealed that a "typical" rehabilitation study lacks sufficient power to detect the empirically-based values. Post hoc power analyses using reported sample sizes and effects indicated the studies were underpowered, with median power ranging from 0.14 to 0.23.

CONCLUSIONS

This study presented novel and empirically-based interpretation guidelines for small, medium, and large rehabilitation treatment effects. The observed effect size distributions differed across intervention categories, indicating that researchers should use category-specific guidelines. Furthermore, many published rehabilitation studies are underpowered.

Protective factors that mitigate the indirect risk of combat exposure upon meaning in life: A longitudinal study of student veterans

OBJECTIVE

Studies of combat emphasize its impact upon health-related outcomes (e.g., depression). Little is known regarding the risk that combat poses to positive outcomes, such as meaning in life, and factors that mitigate this risk. We sought to investigate whether combat poses an indirect risk to life meaning and protective factors that mitigate this risk.

METHOD

Through an online survey at 2 time points, 153 combat-exposed veterans enrolled in college reported combat exposure, health status (posttraumatic stress disorder, depressive, somatic symptoms), meaning in life, and protective factors (social support, instructor autonomy support, coping ability, academic self-efficacy, social and community participation, and meaningful activity). We used path analysis to (a) explore whether baseline health status and life meaning mediated the relationship between combat and follow-up life meaning, and (b) test whether protective factors promoted life meaning despite combat and health status (combat-related risk).

RESULTS

The relationship between combat and follow-up life meaning was mediated by baseline health status and life meaning. Meaningful activity and coping ability were associated with greater life meaning independently of combat-related risk. The indirect effect of combat upon life meaning was weakened when social support, instructor autonomy support, coping ability, and academic self-efficacy were high.

CONCLUSIONS

Combat is associated with worse health status, in turn limiting student veterans' life meaning. This supports an expanded conception of combat-related risk, in which the effect of combat upon positive outcomes is emphasized. Findings indicate that the proposed protective factors may mitigate combat-related risk. We discuss implications for research and practice. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review

BACKGROUND

Evidence-based treatments for service-related health conditions such as posttraumatic stress disorder (PTSD), depression, and traumatic brain injury (TBI) are not effective for all veterans. Equine-assisted interventions are emerging as an additional treatment modality, but little is known regarding the safe and effective delivery of these interventions. This study aimed to describe the following features of the body of literature concerning equine-assisted interventions among veterans: 1) veterans who have participated in equine-assisted interventions; 2) specific characteristics of equine-assisted interventions in veterans; and 3) the specific characteristics of research on equine-assisted interventions in veterans.

METHODS

We conducted a systematic mapping review of peer-reviewed literature reporting on equine-assisted interventions among veterans between 1980 and 2017. Searches of nine databases yielded 3336 unique records, six of which met the inclusion criteria and were reviewed. Data relevant to the study aims were extracted and analyzed.

RESULTS

Equine-assisted interventions among veterans disproportionately targeted psychosocial outcomes and yielded promising results. The detailed methods of EAI varied in the reported studies, ranging from communicating with the horse to mounted exercises. There was also great diversity in outcome measurement. The state of theoretical development regarding the mechanisms by which equine-assisted interventions benefit the veteran population is currently underdeveloped. Studies provided insufficient detail with respect to the description of the intervention, reasons for attrition, and the dose-response relationship.

CONCLUSIONS

Scientific development of equine-assisted interventions targeting psychosocial outcomes among veterans is warranted to establish their efficacy. Targeted outcomes should be expanded, including outcomes more closely aligned with the nature of polytraumatic injuries. Future research must also emphasize the theoretical development of equine-assisted interventions for veterans and thoroughly describe the participants, components of the intervention, factors contributing to attrition, and optimal dose-response relationships.

Participation, Meaningful Activity, and Social Support Among U.S. Student Service Members/Veterans

Student service members/veterans (SSM/Vs) may experience diminished social support and meaningful activity due to health-related sequelae, in turn threatening their community reintegration. Social and community participation may foster both social support and meaningful activity. This study assessed whether social and community participation explained social support and meaningful activity and evaluated the psychometric properties of the Veterans' Social and Community Participation Assessment (VSCPA). Online surveys generated responses to the VSCPA, indicators of social support, meaningful activity, health-related challenges, and demographic characteristics. Multiple regression models explored predictors of social support and meaningful activity. The VSCPA comprised three components: active community participation, familial and household participation, and social participation. These components exhibited positive associations with social support and meaningful activity and negative relationships with health-related sequelae. Targeting social and community participation among SSM/Vs may be a fruitful means by which occupational therapists bolster social support and meaningful activity.