Tools used to measure fear avoidance behaviour in the management of mild traumatic brain injury (concussion)

Concussion can present challenges with respect to diagnosis and management. Fear avoidance behaviour and beliefs may be perpetuating factors in the clinical course of concussion. Understanding which patients may adopt such behaviours and beliefs can offer important information to allow tailoring of clinical management and implementing strategies to minimise the risk of progression to persisting post-concussion symptoms. In this thesis, I: - systematically reviewed the current measurement tools used to assess fear avoidance behaviours and beliefs associated with concussion; - explored the experience of clinicians, researchers and people with lived experience of concussion in relation to fear avoidance behaviours; - developed a new outcome measure using the aforementioned data with adequate content validity (sufficient comprehensibility, comprehensiveness, relevance). I completed a systematic review using the Consensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. This review identified that the current patient reported outcome measures (PROMs) for assessing fear avoidance behaviours in people with concussion have insufficient content validity and should be used with caution in research and clinical practice. I recommended that a new PROM be co-developed with patients, healthcare providers, and researchers. In the second study, I developed a PROM, in three phases, to ensure adequate content validity as per the COSMIN guidelines. In phase one, semi-structured interviews with healthcare providers, researchers and people with lived experience of concussion generated an extensive item list to ensure comprehensiveness. This item list was sent internationally to researchers and healthcare providers who were asked to vote on the relevance of each item. These data were used to create the preliminary measure that was administered in phase three, to people with lived experience of concussion via a semi-structured interview to ensure comprehensibility. Thus, the Fear Avoidance Concussion Tool (FACT) was created, a PROM to be used in the management of concussion by identifying those with concussion exhibiting maladaptive fear avoidance behaviours.