Information interventions for injury recovery: A systematic literature review

Fiona Clay1,2, Alex Collie1,3 & Rod McClure2

1.Institute for Safety Compensation and Recovery Research, Melbourne, Australia2.Injury Research Institute, Monash University3.Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia

Presentation to the Canadian Association of Research on Work and HealthVancouver, 2nd June 2012

Outline

• Why are early information interventions important?

• Review question & methods

• Heterogeneity of studies

• Paper-based interventions

• Face-to-face interventions

• Video/DVD interventions

• Conclusions

Why are early information-based interventions potentially important?

• Lack of information and poor communication with compensation systems are barriers to recovery for injured persons (Lippel, 2007; Roberts-Yates, 2003). • Dissatisfaction, disempowerment, frustration

Secondary victimisation

• The injured persons expectations of recovery are powerful predictors of actual recovery.

• Returning to activity aids injury recovery and return to work, but the default setting is still to ‘rest’ to aid recovery. (Rueda et al, 2012. Am J Pub Health)

Early, effective information provision may improve recovery of injured persons.

Potentially resource efficient & able to be widely disseminated.

Motor vehicle injury?

• WHO estimates that 20 to 50 million people per annum are injured in motor vehicle crashes (Peden, 2005 Int J Inj Cont Safety Promot)

• In Australia in 2011, ~55,000 motor vehicle accident compensation claims were made.

• 60-70% of claimants are of working age.

• In 2000, the annual cost of vehicle related trauma in Australia was estimated to be $18 billion. (Bureau of Transport Economics, 2000)

• In Australia (and other jurisdictions), compensation for motor vehicle accidents is regulated by government statutory authorities similar in nature to workers compensation authorities.

Review Question

“Do targeted early information interventions improve outcomes following vehicle-related traumatic injury in persons of working

age?”

What is an information intervention?

“Group based or individual intervention which predominantly provides education or information about injury recovery including future difficulties, constructive ways of coping or getting back to

normal activities.”

Search Strategy

•Ovid Medline, PsychINFO, EMBASE, Cochrane

•+ hand searching of reference lists

•Period Jan 1990 to April 2011

•PICO format

•Search terms

• Injury terms (eg, wounds and injuries, trauma*) OR

• Motor vehicle terms (eg, automobile, motorcycle) AND

• Information-education terms (eg, internet, pamphlet) AND

• Study design terms (eg, randomised controlled trial)

Inclusion / Exclusion

•Inclusion criteria• Peer-reviewed articles

• English language

• Available as full text

• RCT or pseudo-RCT

• Working age (15 to 64 years)

• >30% vehicle injury

• Recipient of intervention was injured person

• Intervention occurred within 6 months post injury

•Exclusion criteria• Non intervention studies

• Primary prevention studies

• Recipient of intervention was a healthcare provider

• Psycho-education interventions (eg, those that include CBT as a component)

• Mixed information / other intervention studies

• Studies of neck or back schools

Review process

Full text articles retrieved for review by

2 authors N=38

Search resultsDatabase search

(N=807)Hand-searching (N=12)

Total N=819Duplicates removed

N=58

Articles included in the review

N=16 articlesN=13 intervention

studies

Excluded on abstract screen

N=723

Excluded on full text screen

N=22

Risk of bias assessment

Type of Bias Potential Bias

Selection Random sequence generation / Allocation concealment

Performance Blinding of participants and personnelDetection Blinding of outcome assessmentAttrition Incomplete outcome dataReporting Selective reporting on study design or of results

Other Contamination between groups or due to co-interventionsAnalysis was not intention to treatLack of compliance with intervention

• Studies were not excluded on the basis of quality.

• Findings of bias were taken into account when drawing conclusions about the interventions.

Data extracted

•Population• Recruitment method

• Baseline sample size

• Nature of injuries

• Mechanism of injuries

• Inclusion and exclusion criteria

•Study methods• Trial type (RCT or pseudo-RCT)

• Outcome measures

• Follow-up time points

• Statistical analysis

•Intervention• Mode of delivery

• Provider of intervention

• Delivery timeframe

• Reinforcement

• Duration

•Results• Attrition

• Compliance with intervention

• Main results

• Side-effects

Results - heterogeneity of studies

• Injury type• Whiplash / neck pain (N=5)

• Mild traumatic brain injury (N=4)

• Acute stress disorder (N=3)

• Not specified “physical injury” (N=1)

• Follow-up period• 2 to 26 weeks post baseline (N=7)

• >12 months (N=6)

• Comparison conditions• Usual care (N=9)

• Active comparison (N=4)

• Co-interventions (N=3)

• Outcomes• N=75 different outcomes reported

• Symptom severity/frequency

• Mental health / Physical health

• Quality of life

• Health service utilisation

• Employment status / return to work

• Timing of intervention• 24hrs to ~3mths post injury

• Provider of intervention• Nurse (N=4), Self (N=3), Physiotherapist

(N=2), Psychologist (N=1), Therapist (N=1), Clinician (N=1), Not specified (N=1)

Paper-based interventions

• 9 studies

• Format of intervention:

• 1 page pamphlet -> 64 page manual

• 3 studies reported a positive impact

• 4 reported no impact

• 2 studies reported an adverse impact of the intervention

• Both in PTSD –> increase in levels of depression & more request for treatment

Face-to-face interventions

• 6 studies

• Interventions:

• Single session -> multiple sessions conducted over various time periods

• At discharge -> in patient’s home

• Written information also provided in 4 studies

• 5 studies reported no impact

• 1 study reported a positive impact

• Reduction in symptoms following mild TBI

Video / DVD interventions

• 2 studies

• Both whiplash

• 20 minute educational video sent to the patient’s home

• Best practice management of whiplash

• Improved self-rating of pain frequency, severity and location.

• 12 minute educational DVD viewed at patient’s bedside (in hospital)

• Reduced pain ratings, less time away from work, less narcotic use and less health service utilisation.

• BUT….66 outcome measures reported.

Methodological quality

• Generally poor

• All studies rated against CONSORT guidelines for RCTs

• 2 studies scored 12/37

• 2 studies reported 18/37

• No studies reported on all CONSORT items

• Common failure to report important aspects of study design

• Study population

• Compliance with intervention

• Attrition rate

Conclusions

• Heterogenous literature

• Quality of published reports is poor

• No clear evidence of effectiveness of information interventions following motor vehicle injury.

• However…

• ? Does early intervention exacerbate symptoms of PTSD ?

Information interventions remain potentially important.

Well designed, run and reported studies are needed.

For more information

A/Prof Alex Collie

Chief Research Officer,

Institute for Safety Compensation and Recovery Research

Monash University

Melbourne, Victoria, Australia

Twitter - @axcollie

Web – www.iscrr.com.au

“This project is funded by WorkSafe Victoria and the Transport Accident Commission, through the

Institute for Safety, Compensation and Recovery Research.”