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.

Developing A Conceptual Framework for Early Intervention Vocational Rehabilitation for People Following Spinal Cord Injury

PURPOSE

Early intervention vocational rehabilitation (EIVR) can improve return to work (RTW) outcomes for people with spinal cord injury (SCI). However, mechanisms explaining how and why EIVR works are not well understood. This study aims to develop a conceptual framework describing key mechanisms of EIVR intervention effect following SCI.

METHODS

We synthesised data from a realist literature review with data from interviews of people with SCI (n = 30), a survey of people with SCI who had received EIVR (n = 37), a focus group of EIVR providers and a focus group of community vocational providers. We first synthesised the literature review and interviews to develop an initial programme theory describing the contexts in which mechanisms are activated to produce EIVR outcomes. Then we used data from the survey and focus groups to further refine the EIVR programme theory. Finally, a conceptual framework was developed to support knowledge dissemination.

RESULTS

By ensuring consistent messaging across the multi-disciplinary team, EIVR programmes establish and maintain hope that work is possible following injury. Conversations about work allow individuals to determine the priority of work following injury. These conversations can also improve self-efficacy by providing individualized support to envisage pathways toward RTW goals and maintain worker identity. The synthesised study findings highlight the contexts and resources required to trigger activation of these mechanisms.

CONCLUSIONS

EIVR key mechanisms of effect are not specific to SCI as a health condition, therefore enabling this framework to be applied to other populations who face similar impairments and return to work barriers.

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.

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 tāngata whaikaha Māori and disabled people to co-produce policy recommendations around housing and home (kāinga)-developing a nuanced understanding of the contexts in which disabled people can access and maintain kāinga 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 kāinga 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.

Vocational wayfinding following spinal cord injury: In what contexts, how and why does early intervention vocational rehabilitation work?

BACKGROUND: Early intervention vocational rehabilitation (EIVR) is used to optimize return to work (RTW) outcomes for people following spinal cord injury (SCI). However, theoretical clarity is required about how EIVR works, for whom and under what circumstances. OBJECTIVE: To develop a theoretical understanding of how people respond to EIVR following SCI and the contexts in which mechanisms of intervention effect are likely to be activated. METHODS: Realist research methods were used to analyze interviews with 30 participants who had received EIVR following SCI. RESULTS: We conceptualized the reporting of our analyses using a travel metaphor, encapsulating the types and degree of wayfinding support participants required to think about, plan and action their vocational aspirations. Developing, maintaining and enacting hope, supporting self-identity and vocational identity, and focusing on environmental context adaptations required to enact vocational aspirations, appear to be critical mechanisms of intervention effect within EIVR. CONCLUSIONS: Various contexts and mechanisms of EIVR contribute to successful negotiation, achievement and sustainability of RTW outcomes for people following SCI. These theoretical understandings can refine EIVR service provision within SCI rehabilitation and inform how EIVR can improve RTW outcomes for people with acquired neurological conditions in other rehabilitation contexts.

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 after spinal cord injury: A survey of service users

BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.

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.

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/whānau (Māori 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/whānau 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 whānau. 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/whānau 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.