Feasibility of Concussion Rehabilitation Approaches Tailored to Psychological Coping Styles: A Randomized Controlled Trial
Abstract
Objective To evaluate the feasibility of a clinical trial involving participants with concussion randomized to treatments designed to address fear avoidance or endurance coping, which are risk factors for disability. A secondary objective was to evaluate whether each treatment could affect selective change on targeted coping outcomes.Design Randomized controlled trial.Setting Outpatient concussion clinics.Participants Adults (N=73, mean age=42.5y) who had persistent postconcussion symptoms and high avoidance or endurance behavior were enrolled at a mean of 12.9 weeks post injury. Ten participants did not complete treatment.Interventions Participants were randomized to an interdisciplinary rehabilitation program delivered via videoconferencing and tailored to avoidance coping (graded exposure therapy [GET]) or endurance coping (operant condition-based pacing strategies plus mindfulness training [Pacing+]).Main outcome measures Feasibility outcomes included screening efficiency, accrual, credibility, treatment fidelity, adherence, and retention. Avoidance was measured with the Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire and endurance behavior with the Behavioral Response to Illness Questionnaire.Results Screening efficiency, or the proportion of clinic patients who were assessed for eligibility, was 44.5% (275 of 618). A total of 65.8% (73 of 111) of eligible patients were randomized (37 to GET, 36 to Pacing+), meeting accrual targets; 91.7% (55 of 60) of participants perceived treatment as credible. Therapists covered a mean of 96.8% of essential prescribed elements, indicating excellent fidelity. The majority (71.2%; 47 of 66) of participants consistently attended treatment sessions and completed between-session homework. Retention was strong, with 65 of 73 (89%) randomized participants completing the outcome assessment. GET was associated with greater posttreatment reductions in avoidance behavior compared with Pacing+ (Cohen's d repeated measures, 0.81), whereas the treatment approach-specific effect of Pacing+ on endurance behavior was less pronounced (Cohen's d repeated measures, 0.39).Conclusions These findings support a future efficacy-focused clinical trial. GET has the potential to selectively reduce fear avoidance behavior after concussion, and, via this mechanism, to prevent or reduce disability.
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Evidence of the effectiveness of CBT in mTBI is mixed.
“Evidence of the effectiveness of CBT in mTBI is mixed.”
From Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study (2025) · cites this paper as [32]
Silverberg et al presented preliminary evidence that CBT may be beneficial in addressing fear avoidance and endurance behaviours after mTBI.
“Silverberg et al32 presented preliminary evidence to show that CBT may be beneficial in addressing fear avoidance and endurance behaviours after mTBI.”
From Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study (2025) · cites this paper as [32]
The prespecified thresholds for feasibility are based on established benchmarks of previous feasibility trials and the authors' previous experience in recruiting pediatric patients with concussion from an emergency department.
“The prespecified thresholds (criteria for success), as outlined in Table 2 for the feasibility, are based on established benchmarks of previous feasibility trials [47,48] and our previous experience in recruiting pediatric patients with concussion from an ED [49].”
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Self-citationNæss‐Schmidt, E. T., Thastum, M. M., Stabel, H. H., Odgaard, L., Pedersen, A. R., Rask, C. U., Silverberg, N. D., Schröder, A., & Nielsen, J. F. (2022) · Trials · doi:10.1186/s13063-022-06572-7 · Cited by 4 · see citing works
Self-citationProgress in Concussion/Traumatic Brain Injury Science and Clinical Care Over the Last 40 Years
Silverberg, N. D., & Leddy, J. J. (2025) · Journal of Head Trauma Rehabilitation · doi:10.1097/htr.0000000000001102 · Cited by 3 · see citing works
Self-citationSomatic Symptom Disorder After Mild Traumatic Brain Injury
Silverberg, N. D., Rioux, M., Mikolić, A., Perez, D. L., Burke, M. J., & Howard, A. K. (2025) · Journal of Head Trauma Rehabilitation · doi:10.1097/htr.0000000000001068 · Cited by 3 · see citing works
Self-citationJochimsen, K. N., Caron, J. G., Vranceanu, A., & Greenberg, J. (2024) · British Journal of Sports Medicine · doi:10.1136/bjsports-2024-108090 · Cited by 3 · see citing works
Self-citationAmin, S., Mikolić, A., & Silverberg, N. D. (2024) · BMC Neurology · doi:10.1186/s12883-024-03861-3 · Cited by 3 · see citing works
Self-citationPsychological Transdiagnostic Processes in Mild Traumatic Brain Injury Recovery: A Scoping Review
Courchesne, C., Nair, M. A., Gelineau, M., McCloskey, L., Faulkner, J. W., & Cairncross, M. (2025) · Archives of Physical Medicine and Rehabilitation · doi:10.1016/j.apmr.2025.07.014 · Cited by 3 · see citing works
Self-citationMikolić, A., Snell, D. L., Theadom, A., Faulkner, J. W., Zemek, R. L., & Silverberg, N. D. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-089471 · Cited by 3 · see citing works
Self-citationSomatic Symptom and Related Disorders and Mild Traumatic Brain Injury: A Systematic Review
Jobin, K., Wilson, A. J., King, R., Eliason, P., Galarneau, J.-M. F., Gilmour, G. S., & Debert, C. T. (2025) · Psychosomatic Medicine · doi:10.1097/psy.0000000000001427 · Cited by 2 · see citing works
Self-citationCairncross, M., Ledoux, A., Greenberg, J., & Silverberg, N. D. (2024) · Journal of Integrative and Complementary Medicine · doi:10.1089/jicm.2023.0516 · Cited by 2 · see citing works
Self-citationKing, S., Rijkeboer, M. M., Winkens, I., Tuts, N., Ford, M. E., Frankenmolen, N. L., Tanious, R., van der Naalt, J., & Heugten, C. M. V. (2025) · Behaviour Research and Therapy · doi:10.1016/j.brat.2025.104941 · Cited by 1 · see citing works
Shi, S., Fisher, A. J., Rabinowitz, A. R., & Silverberg, N. D. (2026) · Journal of the International Neuropsychological Society · doi:10.1017/s1355617726101854 · Cited by 1 · see citing works
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Self-citationR2Play-Rehab : co-designing a multidomain integrative active rehabilitation tool for concussion
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Concussion rehabilitation through a cervical spine intervention lens: a scoping review
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Self-citationPersisting Symptoms After Concussion and Functional Neurological Disorder: Points of Intersection
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Self-citationPsychological rehabilitation as a factor in the recovery of personal and adaptation resources
Usik, D. A., & Kaminskii, V. V. (2026) · Bulletin of psychotherapy · doi:10.25016/2782-652x-2026-0-98-90-101
- Authors
- Silverberg, N. D., Cairncross, M., Brasher, P. M. A., Vranceanu, A.-M., Snell, D. L., Yeates, K. O., Panenka, W. J., Iverson, G. L., Debert, C. T., Bayley, M. T., Hunt, C., Baker, A., & Burke, M. J.
- Affiliations
- University of British Columbia (CA)
- Vancouver Coastal Health Research Institute (CA)
- Harvard University (US)
- Canterbury District Health Board (NZ)
- University of Calgary (CA)
- University Health Network (CA)
- St. Michael's Hospital (CA)
- Sunnybrook Health Science Centre (CA)
- Corresponding author
- Silverberg, Noah D.
- ORCID
- Venue
- Archives of Physical Medicine and Rehabilitation
- Publisher
- Elsevier BV
- Published
- 2022-08
- Volume
- 103
- Issue
- 8
- Pages
- 1565-1573.e2
- ISSN
- 0003-9993 (ISSN-L)
- OpenAlex
- W4200032830
- Cited by
- 40
- References
- 68
- Citations by year
- 2026: 4 · 2025: 14 · 2024: 10 · 2023: 8 · 2022: 4
- FWCI
- 3.96
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Archives of Physical Medicine and Rehabilitation (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Michael Smith Foundation for Health Research
- Alberta Children's Hospital Foundation
- NFL Foundation
- Spaulding Research Institute
- Canadian Institutes of Health Research
- National Football League Players Association
- Topics
- Health Sciences › Medicine › Epidemiology › Traumatic Brain Injury Research
- Health Sciences › Medicine › Neurology › Long-Term Effects of COVID-19
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
- Keywords
- concussion, post-concussion symptoms, fear avoidance, pacing strategy, mindfulness training, interdisciplinary rehabilitation, videoconferencing, intervention fidelity, trial feasibility, treatment retention, medication adherence
- MeSH terms
- Adaptation, Psychological, Adult, Brain Concussion, Feasibility Studies, Humans, Surveys and Questionnaires, Post-Concussion Syndrome
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