Background & Aims

Comorbid chronic Whiplash Associated Disorder (WAD) and PTSD can be debilitating and associated with poor recovery [1]. Best practice treatment is limited but recent findings indicate integrated psychological and physical exercise treatments show promise in reducing pain-related disability [2]. However, it is unknown to what extent treatments are implemented as intended (fidelity) or whether other factors cause treatment benefits [3-4]. Lack of consensus on measuring treatment fidelity [5] relates to treatment complexity, more onerous in comorbid cohorts [6]. Previous studies focused on treatment delivery, as patients often receive modified versions of original interventions [7]. Suggested treatment fidelity measures vary between specific intervention approach [7-8] or single focused outcome tools [5]. Our aim was to develop and evaluate a comprehensive fidelity tool to examine treatment fidelity of a previously tested integrated treatment approach for comorbid chronic WAD and PTSD.

Methods

A secondary analysis was conducted of audio-recorded psychologist treatment sessions from an RCT testing two integrated interventions for patients with chronic WAD and PTSD [2]; trauma-focused cognitive behavioural therapy or supported therapy, both with exercise. During development of the fidelity tool, 10 sessions from 3 patients were analysed blind to condition to ascertain how best to apply fidelity. Conceptual frameworks [3,9] were adapted to capture core fidelity domains with subject matter expert guidance (clinical psychologist; whiplash expert). A fidelity tool consisted of 41 items including 3 previously validated measures and a purpose-built treatment checklist. The tool was independently applied to one participant’s 10 sessions. During evaluation, a second version was applied to 12 sessions randomly selected by an unblinded author. Two psychologists trained in the protocol independently applied the tool to the first 4 sessions of 2 participants receiving different treatment.

Results

The fidelity observational tool included 7 domains: frequency, duration, program differentiation, alliance, participation responsiveness, quality of delivery, and intervention complexity. Raters were consistent in their scoring on 3 domains; duration, frequency and program differentiation. Minor discrepancies related to program differentiation included the extent to which a treatment technique was explored and put into practice during the session. Both raters identified challenges with assessing therapeutic alliance. For both participants, raters reported discrepancies in participation responsiveness (e.g. effort during in and outside of sessions). Raters also noted differences in therapist quality for one participant and variability in reports of chronic WAD and PTSD symptoms.

Conclusions

We developed a new multi-dimensional treatment fidelity observational tool to assess treatment fidelity of integrated treatments for comorbid chronic WAD and PTSD. Preliminary findings suggest that the tool could assist researchers in determining treatment fidelity though further refinement and evaluation is required. Measuring treatment fidelity ensures treatment delivery is both consistent and reliable. Although time and labour intensive, greater attention to the methods of fidelity analysis will provide assurances in the quality-of-care patients receive and may guide future treatment designs.

References

1. Ravn, S. L., Karstoft, K. I., Sterling, M., Andersen, T. E. (2019). Trajectories of posttraumatic stress symptoms after whiplash: A prospective cohort study. European journal of pain (London, England), 23(3), 515–525.

2. Andersen, T., Ravn, S., Armfield, N., Maujean, A., Requena, S., Sterling, M. (2021) Trauma-focused cognitive behavioural therapy and exercise for chronic whiplash with comorbid posttraumatic stress disorder: a randomised controlled trial. PAIN. 162(4): 1221-1232.

3. Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation science: 2, 40.

4.Toomey E, Hardeman W, Hankonen N, Byrne M, McSharry J, Matvienko-Sikar K, Lorencatto F. (2020) Focusing on fidelity: narrative review and recommendations for improving intervention fidelity within trials of health behaviour change interventions. Health Psychol Behav Med. Mar 12;8(1):132-151.

5. Feely, M., Seay, K., Lanier, P., Auslander, W., Kohl, P. (2018) Measuring Fidelity in Research Studies: A Field Guide to Developing a Comprehensive Fidelity Measurement System. Child Adolesc Soc Work J. 35, 139–152.

6. Mars, T., Ellard, D., Carnes, D., Homer, K., Underwood, M., Taylor, S. J. (2013). Fidelity in complex behaviour change interventions: a standardised approach to evaluate intervention integrity. BMJ open, 3(11), e003555.

7. Walton H, Spector A, Tombor I, Michie S. (2017) Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: a systematic review of measure quality. Br J Health Psychol. 22(4):1–19.

8. Walton, H., Spector, A., Williamson, M., Tombor, I., Michie, S. (2020). Developing quality fidelity and engagement measures for complex health interventions. British Journal of Health Psychology. 25(1): 39–60.

9. Camões-Costa, V., Chakraborty, S., Mozaffari, F., Collie, A., Kenardy, J., Brijnath, B., Mortimer, D., Enticott, J., Kidd, M., Trevena, L., Reid, S., & Mazza, D. (2023). Assessing the fidelity of a behavioural intervention involving academic detailing in general practice: a sub-study of the ‘Implementing work-related Mental health guidelines in general PRacticE’ (IMPRovE) trial. Implementation science communications, 4(1), 154.

Presenting Author

Leone Bennett

Poster Authors

Leone Bennett

MSc Med (Pain Management)

The University of Queensland

Lead Author

E-mail

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Neck Pain