Background: Mild traumatic brain injury (mTBI) affects tens of thousands of athletes yearly. The diagnosis and the monitoring of this frequent injury among university athletes remain a challenge for healthcare professionals, encouraging research to look at innovative ways to assess and monitor mTBI, in various areas to allow for save return-to-play (RTP). Recently, perceptual-cognitive performance, as well as self-efficacy, have gained popularity among healthcare providers.

Objective: The aim of this study was to explore the effect of sustaining a mTBI on perceptual-cognitive performance and self-efficacy in athletes when comparing preseason (pre-injury) values to acute post-injury and return-to-play values.

Methods: University varsity athletes from the Université of Québec in Trois-Rivières (n=159) completed a Neurotracker and self-efficacy preseason (PS) baseline assessment. Participants who sustained a mTBI during the sporting season joined the post-injury phase and underwent a 48-72 hour post-injury (T1) and a RTP (T5) assessment. The perceptual-cognitive functions were assessed on the Neurotracker, where a mean speed threshold (MST) is established after three blocks of 20 trials. Self-efficacy related to athletic skills and mTBI presentation related to physical activity scores were obtained by completion of two questionnaires. Wilcoxon signed-ranked test was performed to compare Neurotracker and self-efficacy PS, T1, and T5 scores.

Results: 20 student-athletes (9 females) sustained a mTBI and joined the post-mTBI phase. The average number of days between mTBI and T5 was 15.17±2.48 days. A significant difference was found between T5 Neurotracker MST and T1 Neurotracker MST (z=-2.52, p=0.01), with higher MST being noted at T5. Significant differences between T1 and PS in self-efficacy questionnaire related to athletic skills scores (z=-3.10, p=0.00) were reported, suggesting that T1 scores were lower. Significant differences were found between T5 and PS (z=-2.21, p=0.03) and between T5 and T1 (z=-2.52, p=0.01), suggesting that T5 athletic skills scores were lower than PS and T1 scores. There were significant differences between T1 and PS in mTBI presentation related to physical activity self-efficacy scores (z=-3.15, p=0.00), suggesting that T1 scores were lower. A significant difference was found between T5 and PS in mTBI presentation related to physical activity self-efficacy scores (z=-2.53, p=0.01) with lower scores at T5. Significant differences were also observed between T5 and T1 (z=-2.67, p=0.01) suggesting that T5 scores were lower.

Conclusion: This study indicated that perceptual-cognitive performance, as assessed by the Neurotracker, does not seem to be affected by the mTBI in the acute phase. However, the learning gains of a perceptual-cognitive task seem to be negatively impacted by the mTBI and to be normalizing after repeated exposure to the Neurotracker. Furthermore, the results showed that the athlete’s self-efficacy related to athletic skills and physical activity can be significantly decreased by the mTBI in the acute phase and at the RTP.

Introduction: Concussion may be a common precipitant of functional cognitive disorder (FCD). FCD is characterized by persistent, distressing cognitive symptoms not fully explained by structural brain injury. While some treatment options for FCD after concussion have been explored, there is limited research on patient characteristics associated with treatment response in this population. The current study explores potential predictors of treatment outcome.

Methods: Secondary analyses were conducted using data from a recent pilot clinical trial (ClinicalTrials.gov ID: NCT05581810) that randomized participants with FCD after concussion to cognitive behavioural therapy (n=11) or cognitive rehabilitation (n=13). The sample consisted of adults with a multidisciplinary consensus diagnosis of FCD [19 women, mean age=41.0 years (SD=12.6), mean time since concussion=17.1 (SD=4.9) months]. We predicted that lower depressive symptoms (Patient Health Questionnaire-9; PHQ-9), higher treatment expectancy (Credibility/Expectancy Questionnaire - Expectancy subscale), greater resilience (Connor-Davidson Resilience Scale), and higher FCD severity (based on number of internal inconsistencies) at baseline would predict better treatment outcome. The primary outcome was the Multifactorial Memory Questionnaire-Satisfaction subscale (MMQ-S; lower scores indicated greater memory concern). Multivariable regression models for each candidate predictor were conducted using the combined sample (N=24), as we previously found no differences between the treatment arms. In all models, pre-treatment MMQ-S scores were included as a covariate and post-treatment MMQ-S scores as the dependent variable. In supplemental analyses, we compared treatment outcomes in participants with high vs. low pre-treatment scores and explored treatment process variables as secondary outcomes.

Results: Depression had a medium effect on post-treatment MMQ-S scores (standardized β=-0.43, 95% CI [-1.00, 0.15]) and, together with pre-treatment MMQ-S scores, explained 13.8% of the variance in post-treatment MMQ-S scores. Participants with high pre-treatment depression symptoms (PHQ-9 ≥ 10; n = 12) had MMQ-S post-treatment scores that were 5.6 points lower (95% CI [-3.02, 14.28], standardized mean difference = 0.66) than the non-depressed group, controlling for pre-treatment MMQ-S scores. Higher pre-treatment PHQ-9 scores were associated with lower homework adherence (r=-0.26, 95% CI [-0.61, 0.18]) and more no-shows (r=0.43, 95% CI [0.03, 0.71]). Treatment expectancy (standardized β=0.01, 95% CI [-0.45, 0.47]), resilience (standardized β=0.09, 95% CI [-0.36, 0.54]), and FCD severity (standardized β=0.05, 95% CI [-0.46, 0.56]) were not associated with MMQ-S post-treatment scores.

Conclusion: Depressive symptoms may interfere with treatment engagement and hinder outcomes. Treatment expectancy, resilience, and FCD severity were not associated with response to treatment in this small sample. A large proportion of variance in treatment outcomes was unexplained by measured baseline variables, suggesting that other factors, such as therapist- and treatment-specific variables, should be explored in future research.

Introduction: Cognitive deficits resulting from traumatic brain injury can have significant impacts on daily living hindering the ability to perform complex tasks such as meal preparation. Assistive technologies for cognition (ATCs), like the Cognitive Orthosis for coOKing (COOK), are designed to mitigate these deficits. The configuration of COOK, carried out by occupational therapists, must allow them to personalize the interventions provided by COOK to their patients’ needs. In a prior study by our research team, occupational therapists were shown a mock-up of the configuration interface and they recommended numerous modifications. However, no consensus was reached on the priority or feasibility of these changes. Results also suggested the importance for therapists to test the configuration interface to assist the team in ensuring the interface’s usability.

Objectives: The aim of this study was to (a) Document occupational therapists' perceptions on priority modifications for version 8 of COOK’s configuration interface mock-up, while also considering the computer science team’s opinions on their feasibility; and (b) Describe the perceived usability of COOK’s configuration interface by occupational therapists during the configuration process, in a laboratory setting.

Methods: For the first objective, the TRIAGE method (Gervais & Pépin, 2002) was used with 6 occupational therapists and 2 members of our computer science team, to reach consensus on the priority and feasible modifications to be made to COOK’s configuration interface. Then, occupational therapists (n = 9) participated in a simulated configuration of COOK in a laboratory setting using a case study of a person with severe TBI. The Think Aloud method was used to explicit their clinical reasoning, and participants completed the French System Usability Scale questionnaire (F-SUS). All sessions were audio and video recorded, and the data were analyzed using the deductive thematic analysis approach described by Miles et al. (2018).

Results: Six main modifications were deemed feasible and a priority by participants. The chosen modifications - such as scheduling strategic breaks during meal preparation, adjusting portion sizes to the patients’ needs, integrating a vocal assistant, and customizing recipes and cognitive strategies - reflect occupational therapists’ focus on patient safety, goals, and needs. Participants also accounted for clinical time constraints by choosing the addition of a baseline configuration. Moreover, preliminary data analysis and the F-SUS score (78,33%) suggest a good usability level of COOK’s configuration interface considering occupational therapists’ efficiency, efficacy and satisfaction when carrying out the configuration process.

Conclusions: This study offered key insights into priority adaptations needed for COOK’s configuration interface to better suit occupational therapists’ needs. It also provided an initial opportunity for occupational therapists to familiarize themselves with the interface. The findings will guide usability improvements of this interface, enhancing occupational therapists’ experience and encouraging greater adoption of COOK in clinical practice.

Sex, fatigue and subjective sleep disruption have been shown to be associated with poor subjective recovery after mild traumatic brain injury (mTBI). This study aimed to determine whether the relationship between these factors and post-concussion symptom (PCS) reporting are unique to individuals who have incurred a mTBI. A group of 208 pre-morbidly healthy adults was assessed with measures of fatigue (Multi-dimensional Fatigue Inventory), subjective sleep disturbance (Pittsburgh Sleep Quality Index), depression (Inventory of Depressive Symptomatology) and anxiety (Beck Anxiety Inventory) symptomatology, and PCS endorsement (Rivermead Post Concussion Symptoms Questionnaire). Individuals who were admitted to hospital approximately 8-weeks prior with systemic traumatic injury and mTBI (mTBI; n = 86) and with systemic traumatic injury without head strike (TC; n = 46) had equivalent and elevated levels of fatigue, subjective sleep disturbance and PCS endorsement relative to a healthy community-based control sample (HC; n = 76). Female sex (p = .028) and an elevated sense of general tiredness (p = .037) were significant independent predictors of PCS endorsement in the mTBI group, but sex did not independently predict PCS reporting in either the trauma or healthy control groups (p > .05). Psychological status was the only variable that independently predicted PCS reporting in all groups. This study suggests that the vulnerability of females to report elevated PCS in the post-acute period after traumatic injury may be specific to those who have incurred a concomitant mTBI. The factors that may be contributing to this pattern of performance will be highlighted. Further, only some subcomponents of fatigue are independent predictors of PCS reporting, with the groups showing variability in these associations. This suggests that more detailed consideration of fatigue subcomponents may be warranted when treating or managing these individuals.

Background: Coping with disabilities in midlife due to a stroke can be particularly challenging, as this stage of life often involves multiple roles and responsibilities. The challenges during midlife after stroke may differ between the genders. This study aimed to explore potential gender differences in QoL and resilience after stroke using both quantitative and qualitative methods.

Methods: For the quantitative analysis, demographic, medical data and questionnaires (Riksstroke questionnaire, SF-36, Connor-Davidson Resilience Scale) were retrieved from a stroke register including 51 individuals (22 men) aged 18-64. Two-sided t-test and chi-square test were used to analyze the data. This was complemented by eight semi-structured telephone interviews with four men and four women, between 45-60 years. Qualitative content analysis was used to analyze the interview data.

Results: There were no statistically significant differences between the genders in the quantitative results. Three themes emerged from the qualitative analysis: 1) A forced lifestyle change, 2) Lack of understanding and support, and 3) Importance of independence and coping strategies. Men described their limitations in broader terms expressing that these challenges hindered their lives and highlighted a need for more support from relatives, friends and health care providers. In contrast, women provided more nuanced descriptions, indicating that they had developed coping strategies and experienced better QoL with higher levels of resilience.

Conclusions: Although the dataset includes a relatively small number of participants in both the quantitative and qualitative analyses, the qualitative findings suggest gender-related differences in QoL after stroke during midlife. These differences were not captured in the quantitative analysis and highlight the need for in-depth qualitative studies to further investigate gender differences in this area.

Purpose: Mild traumatic brain injury (mTBI) is 90% of all traumatic brain injuries seen in U.S. emergency departments (ED). The “mild” classification of mTBI (same as concussion) masks the significant impact on the healthcare system and must include the contribution of increased aging populations. In the U.S., those aged ≥ 65 (older adults) with mTBI incur twice the costs compared to those aged < 65. Notably, older adults continue to experience symptoms 1-5 years after mTBI, negatively impacting their quality of life. Although associations between fall injury and older adults are reported, research on falls and ongoing mTBI symptoms in older adults is underdeveloped. Additionally, research on payor sources and discharge outcomes in older adults with mTBI is limited. The purpose of this study is to explore relationships among fall injury, payor sources, and discharge outcomes (referral to healthcare services) in individuals aged ≥ 65 with mTBI in subsequent ED visits.

Methods: The study is a cross-sectional design using secondary population data from the Nationwide Emergency Department Sample (NEDS) 2018 dataset. The descriptive analysis describes characteristics within mTBI subsequent visits. The logistic regression ascertains the relationship in mTBI subsequent visits among age, falls, payor sources (Medicare, Medicaid, private, other), and healthcare services.

Results: The study sample size is 4932. The significant associations include fall injury and referral to healthcare service visits (p< 0.05, χ²₁=123.6), and Medicare and referral to healthcare services (p< 0.05, χ²₃=1059.9). The odds ratio for populations aged ≥ 65 (OR 4.172, p< 0.05, CI 95% 3.427, 5.079), falls (OR 3.847, p< 0.05, CI 95% 2.649, 5.587), and Medicare (OR 4.492, p< 0.05, CI 95% 1.273, 2.106) have an increased probability of referral to healthcare services.

Conclusions: The findings support geriatric populations, falls, and Medicare carriers have an increased probability of being referred to healthcare services in those who are being readmitted to the ED for persisting symptoms after mTBI. Future research in fall prevention and aggressive medical monitoring after an initial mTBI, may inform current discharge models of care.

Clinical Relevance: Interdisciplinary collaboration to educate on mTBI and fall prevention is needed in individuals aged ≥ 65.

Background: Cognitive-communication impairments are common after acquired brain injury (ABI) and can negatively impact a person’s return to work, social functioning, community independence and quality of life. Training a communication partner (e.g. family member, friend and/or carer) can improve the communication skills of the person with ABI, however, families are dissatisfied with existing communication partner training (CPT) and support. There is emerging evidence for the effectiveness of training for communication partners, though there is variability in the content, dosage and delivery of training. The strongest evidence is for a single programme, TBI Express, which has three different versions, though is rarely used by speech and language therapists. There is a need to guide future delivery of CPT to ensure that the minimum active ingredients are delivered regardless of content and dosage. Therefore, the aim of this study is to identify and describe the active components of the three versions of TBI Express for people with cognitive-communication disorders.

Method: The treatment manual from each of the training programmes (i.e., TBI Express, TBI Express-Adapted, and TBIconneCT) was coded using the BCTTv1. Mechanisms of action (MoA) and each behavioural change techniques (BCT) were identified and linked using the theory and techniques tool. Reliability of coding (% agreement) was conducted for two modules representing ~20-33% of treatment content.

Results: 27 unique BCTs (range 20-25) were identified linked to 16 unique MoAs (range 15-16). The most common BCTs were providing information about social and environmental consequences; instruction on how to perform the behaviour; behavioural practice/rehearsal; and feedback on the behaviour. The most common mechanisms targeted were beliefs about capabilities; skills; and behavioural regulation. Reliability of coding BCTs and MOAs ranged from 47-50% for the first programme and increased to 67-81% for the third programme. Agreement increased as coding progressed with clearer guidance needed on the definition of the target behaviour of CPT compared with the desired outcome from achieving the target behaviour.

Conclusions: Applying behaviour change theory to TBI express has revealed unique insight into the active ingredients of training. Communication partners are anticipated to improve their communication behaviours via capabilities, skills and regulation, through SLT-delivered CPT which focuses most commonly on information provision, instruction, rehearsal, and feedback. Such insights are gathered to further refine and adapt existing interventions. The challenge of discriminating between target behaviours and desired outcomes highlights the need for further conceptual work. Future work is now needed to identify the most important active ingredients to practicing clinicians, to design and test the feasibility of an adapted CPT programme for use in the mainstream health service.

Context: Cognitive, psychological, sleep, and fatigue issues are common and persistent consequences of acquired brain injury (ABI). While non-pharmacological interventions can be effective, they are not always accessible. Self-help online interventions offer a promising alternative but may not be suitable for all patient profiles. In the last few years, the RESILIENT platform was developed and tested as a blended intervention for psychological and sleep problems in the context of a traumatic event.

Objectives: This study aims to explore the perceptions of rehabilitation clinicians on the feasibility and usability of a self-help online intervention for the ABI population (RESILIENT) and to identify necessary adaptations.

Methods: A focus group was conducted with six clinicians (four neuropsychologists, one physiotherapist, one social worker, including two clinical coordinators) from the traumatic brain injury and encephalopathy programs of a university-affiliated rehabilitation center in Québec, QC, Canada. Clinicians reviewed the existing platform before the focus group, where they discussed the applicability of a self-help treatment with adults with ABI and the necessary adaptations to the content and format of the intervention. A thematic analysis was performed on the transcribed verbatim of the focus group.

Results: Clinicians generally liked the idea of an adapted platform for patients with ABI but had mixed opinions about fully autonomous self-administered treatment. Most viewed this intervention as a complement to rehabilitation services, requiring support from a trained support facilitator. Some saw RESILIENT as a way to fill service gaps, such as for patients on waiting lists, after discharge from rehabilitation, or living in rural areas. Barriers identified by participants included aphasia, apathy, hemineglect, hemianopsia, physical challenges with computer use, poor self-awareness, and lack of access to technology. To make the intervention suitable for individuals with ABI, clinicians suggested reducing and simplifying text, adding more images and examples, and incorporating rewards to foster motivation. They also recommended addressing additional topics, such as fatigue, substance use, behavior management, lifestyle habits, intimacy, and psychoeducation on ABI, as well as content for caregivers. C

Conclusion: While the RESILIENT online self-help platform shows therapeutic potential, it requires adaptations to better suit ABI patients. Future studies will assess the efficacy, feasibility, and acceptability of the adapted treatment.

Introduction: Event segmentation refers to parsing the continuous flow of our daily activities into discrete meaningful events (Richmond et al., 2017). Non-normative segmentation (i.e., when individuals do not identify the same event boundaries as others) has been associated with poorer memory performances in both healthy individuals and those with acquired brain injury (ABI; Zacks et al., 2016). This may partly explain the episodic memory difficulties frequently observed in this clinical population (Vakil et al., 2019). However, these results were obtained in a laboratory setting by asking participants to segment third-person videos. It remains to be determined whether the segmentation difficulties of brain-injured patients can be observed using a more ecological paradigm (inspired by the one used in Jeunehomme & D’Argembeau, 2020), and their impact on personal everyday memories.

Objective: Examining the segmentation abilities of brain-injured patients with an ecological segmentation task and determining whether these abilities predict everyday events memories assessed with a paradigm based on the sampling of daily life experiences.

Methods: Seven brain-injured patients and their matched controls were asked to perform a series of actions during a walk on a university building with a wearable camera. One week later, they were presented with a video of their walk and were instructed to segment it into meaningful events. To assess participants’ everyday memories, they had to answer questions sent on their smartphone 5 times a day for one week about what they were doing at the present time (the people they were with, the emotions they were feeling, the place where they were, etc.). At the end of the week, they were asked to verbally report 5 of these personally experienced events in as much detail as possible. An accuracy score was obtained by comparing information from their verbal reports to those recorded on the mobile application.

Results: Healthy participants had a significantly better segmentation agreement than the clinical group (t = -4.35 ; p <.001 ; d = -2.02) and their memories of everyday events were more accurate (t = -2.31 ; p = .03 ; d = -1.07). The linear regression exploring if the segmentation score predicted memory performance on the whole sample did not reach significance (t = 0.96 ; p = .35 ; f² = 0.32) but this could be explained by the small number of participants.

Discussion: These preliminary results seem to confirm the segmentation difficulties of brain-injured patients and provide new insights into the cognitive changes that occur after an ABI. A larger sample will determine whether these difficulties are predictive of memory performance in everyday life, which could open new avenues for rehabilitation programs aiming at reducing memory difficulties by training brain-injured patients to segment in a more normative way.

Background: Cognitive-communication disorders (CCDs) can have a devastating effect on people’s lives after acquired brain injury (ABI), as well as those around them. In comparison with other specialised areas of speech-language pathology (SLP), such as post-stroke aphasia, research in CCDs after ABI is relatively new. Globally, researchers interested in supporting people with CCDs after ABI is small, yet highly motivated, and from diverse geographical regions. It is rare yet special when global mid-career researcher colleagues meet in-person and have ‘corridor’ conversations that explore specific and forward-thinking research ideas and threads. These conversations between researchers lead to idea generation, collaborations, knowledge sharing, and have the potential to progress the field of cognitive-communication rehabilitation. Because frequent interactions can foster ongoing international collaboration and advance the empirical evidence base for CCDs, this presentation reports on the conceptualisation and development of an international group of CCD mid-career researchers with this aim.

Methods: Following an international conference, a collaboration of international, mid-career researchers participated in regular conversations via video-teleconferencing. Meetings were held monthly during 2024, with those able to attend joining the online conversation, and those unable to attend contributing to brainstorming ideas via email and online software.

Results: The group has diverse expertise across the lifespan, including qualitative and mixed methods approaches. Specialist interest areas include: accurate assessment, discourse methods, visual elicitation materials, communication partner training, interpersonal relationships, project-based interventions, social media, digital health tools, return to school, military and veterans’ health research, interventions for dementia and caregiver training, educational impacts, patient-provider communication, communication across modalities, empathy training, and participatory co-design. The team, self-named CIRCLE (Cognitive-Communication Researchers Linked for Excellence), are highly invested in research projects that prioritise cross-cultural perspectives, meaningful rehabilitation options, and are co-designed with people with ABI from the outset to amplify their voices and incorporate their perspectives and expertise. Brainstorming has generated short-term goals for the group including collaborations on small projects and building international grant proposals. Long-term goals include building awareness of CCDs internationally, including potential for a shareable 'textbook' for clinicians, e.g., short videos of key information for social media. Our presentation will explore our ideas and invite discussion around the group’s goals for the future, including dissemination and implementation as well as modelling through participatory co-design.

Conclusion: This international research collaboration represents the next generation of researchers striving to create meaningful and significant contributions to the field of CCDs after ABI. Diverse experiences across countries, healthcare systems and areas of expertise can allow for innovative problem-solving in ABI. Our presentation will highlight how finding your CIRCLE may provide sustainable practices for international collaborations and build critical evidence-based guidance for ABI rehabilitation, as well as for successful health communication and advocacy in this space.

The objective of the study was to examine the experiences of individuals with Acquired Brain Injury (ABI) and their partners regarding the effects of social cognition problems on their relationships. A qualitative interview study was conducted. Interviews were conducted one to five years post injury, either in the participants’ home or at an ABI care facility in the Netherlands.
The participants were nine couples consisting of an individual with ABI and a partner without ABI. Scores on neuropsychological tests of the partnes with ABI indicated social cognition difficulties in individuals with ABI.
Individual semi-structured interviews were conducted, audio recorded, and transcribed verbatim. Two independent analysts analyzed the data using thematic analysis aimed at finding common themes across the data set. Data analysis was carried out recursively and parallel to data collection to help determine when saturation was reached.
Six themes were generated from the interview data: (1) Partners feeling disappointed, lonely, and despondent, (2) Individuals with ABI feeling insecure and ashamed of falling short, (3) Relationship roles changing, (4) The aggravating role of fatigue and sensory hypersensitivity, (5) The importance of professional help, and (6) Silver linings: Increased awareness creating closeness.
We concluded that social cognition problems have the potential to strongly affect relationships between those with ABI and their partners in many ways. Addressing social cognition problems early is recommended as it is greatly appreciated by individuals with ABI and their partners and holds promise for improving their relationship.

Introduction: A prescription of targeted heart rate aerobic exercise (THRAE) in athletes with acute sport-related concussion (SRC) facilitates recovery and reduces the incidence of delayed recovery (Persisting Post-Concussive Symptoms) in randomized controlled trials (RCT). Studies have attempted to control for sex by ensuring equal distribution of males and females. These studies showed there are no differences in recovery time between the sexes, however no studies have examined the effect of THRAE in males and females separately.

Methods: We conducted a systematic review of studies of THRAE in both male and female athletes within 2 weeks of SRC that had a control group. Searches were run in September 2023 in five databases: CINAHL Plus with Full Text (EBSCO), Embase (Elsevier), PubMed, SPORTDiscus with Full Text (EBSCO), and Web of Science Core Collection. Studies were deduplicated and added to Covidence where they were reviewed by 2 independent reviewers to see if they controlled for participant sex. No risk of bias for included studies was performed. We authored two of the included studies, so we were able to reanalyze the data using survival analysis after stratifying by participant sex.

Results: We identified 1031 studies, out of which 7 were relevant. No study examined the effect of intervention by sex. One study showed no differences in sex distribution between groups, one included the main effect but not the interaction of sex in their survival analysis, and one showed no difference in recovery time between males and females without stratifying by aerobic vs. stretching exercise intervention. The remaining 4 studies’ sample sizes were too small to compare the sexes. On reanalysis of RCT 1 (Leddy et al. 2019), males prescribed THRAE recovered 6 days faster than controls (12 vs 18 days, p=0.035) whereas females recovered only 3 days faster (13 vs 16 days, p=0.761). On reanalysis of RCT 2 (Leddy et al. 2021), males prescribed THRAE recovered 7 days faster than controls (13 vs 20 days, p=0.099) whereas females recovered 1 day after controls (18 vs 17 days, p=0.456).

Conclusion: THRAE seems to be more effective for concussed male adolescent athletes than for females. An equal number of males and females in intervention groups is not an effective method of controlling for sex in exercise for concussion studies. Future studies investigating the effect of exercise for concussion treatment should have a large enough sample to stratify analyses by sex.

Background: Sport-related concussion (SRC) is a public health concern and there are some reports of different recovery trajectories between the sexes. Advanced neuroimaging techniques such as diffusion magnetic resonance imaging (dMRI) reveal microstructural brain changes after concussion. dMRI has been used to investigate SRC in adolescents but few studies have included structural network measures regarding connectivity between brain regions and diffusion measures regarding white matter integrity. We investigated structural network and diffusion whole-brain changes in concussed versus non-concussed adolescent athletes. We hypothesized that there would be structural whole-brain differences between groups.

Methods: dMRI data (multishell [b=1000, b=2000, 46 directions] whole brain scans) were collected from 13–18-year-old adolescent athletes (n= 35) within 10 days of SRC (baseline) and after clinical recovery (follow-up). Age and sex-matched controls (n= 34) had the same data collected at baseline and 4-6 weeks later. dMRI data were preprocessed to control for artifacts and quality control was performed on the data. Two participants had poor quality data, so one concussed female and one control male were excluded. A population specific atlas was chosen, and generalized q-sample imaging (GQI) was used for reconstruction. Network and diffusion measures were calculated using the Brain Connectivity Toolbox and DSI Studio, respectively. Statistical analysis was performed using linear mixed effect models and the Network-Based Statistics toolbox.

Results: There were limited differences between the concussed and control groups and no differences between the acute injury and post-recovery timepoints. Females had greater clustering coefficients, global dissimilarity, mean diffusivity, and radial diffusivity than males. Network-based statistics showed that females had greater connectivity strength versus males and that controls overall had greater connectivity strength versus concussed. The group by sex interaction revealed that the difference in connectivity between the groups was modulated by sex. Specifically, post hoc analyses stratified by time point and sex indicated that control males had higher connectivity strength versus concussed males at both baseline and follow-up timepoints.

Discussion: Although females had greater connectivity strength than males, there were no significant differences in connectivity strength between concussed and control females. The significant results of the group by sex interaction suggest that male connectivity is more vulnerable to the effects of concussion. These results suggest that females have a different structural response to concussion than males and highlight the need for further investigation into sex-specific microstructural responses to concussion and correlation with clinical presentation and recovery.

Case Description: A 40-year-old male with acute multifocal stroke status-post tenecteplase and thrombectomy. An otherwise healthy patient presented with a basilar artery occlusion and was treated with tenecteplase followed by thrombectomy. The procedure was complicated by showering multifocal infarcts. Initially, the patient progressed well during acute rehabilitation. However, approximately six weeks post-thrombectomy, he developed fevers, diaphoresis, tachycardia, posturing, and elevated blood pressure. An infectious workup, EEG, and brain MRI were negative. Due to these events, he regressed in therapy progress and was transferred to our acute rehabilitation facility. Upon admission, the patient scored 17 on the Paroxysmal Sympathetic Hyperactivity (PSH) Assessment Measure, confirming the diagnosis of PSH.

Assessment/Results: Given the patient's polypharmacy, initial management focused on weaning off medications that could exacerbate symptoms. Propranolol was started for prevention, and clonidine was used for abortive therapy. Propranolol was later uptitrated, and clonazepam was added to further control symptoms. Optimizing the sleep-wake cycle was also prioritized. After six weeks, the patient’s PSH score improved to 3, leading to increased wakefulness and participation in therapy. This allowed for significant and consistent progress toward rehabilitation goals by discharge.

Discussion: This case highlights the rare occurrence of late-onset PSH in a non-traumatic brain injury patient. While literature reports the median onset of PSH after stroke is around five days, this case demonstrates a delayed presentation. The PSH Assessment Measure can be a valuable tool for diagnosing autonomic dysfunction in brain injury cases with varied etiologies.

Conclusion: PSH should be considered and assessed in patients exhibiting autonomic dysfunction following severe brain injury, regardless of timing.

The purpose of our research was to investigate if high-amplitude microsaccades identified during Videonystagmography (VNG) testing are correlated with concussion history. A total of 219 people, between the ages of 14 and 81, participated in this study. Of these 219 subjects, 64 reported no history of concussion while 155 reported a history of concussion were assessed with VNG looking for the presence of high-amplitude (abnormal) microsaccades. The VNG test battery included: Tracking / Smooth Pursuits, Saccades, Optokinetic, Gaze Testing, Spontaneous Nystagmus, Torsion Swing, Active Head Rotation, Positional Tests (Supine Head Center, Supine Head Left, Supine Head Right, Body Left, Body Right), Dix Hallpike and Caloric testing. Normal microsaccades are critically related to many aspects of visual perception, attention and cognition. On average, an individual executes about 1-2 microsaccades per second. For purposes of this study greater than 2 microsaccades per second was considered abnormal. After analyzing the sensitivity for each test individually we analyzed the percentage of subjects who demonstrated high-amplitude microsaccades. 88% of subjects with concussion demonstrated high-amplitude microsaccades in at least 1 of the above listed VNG tests. To simplify the assessment we identified the 3 highest sensitivity tests and created a 3-test cluster (gaze, saccadic, and positional testing). 78% of all subjects demonstrated high-amplitude microsaccades during at least 1 test of this 3-test cluster. Of those subjects who identified as having suffered from multiple concussions, 92% demonstrated high-amplitude microsaccades with our 3-test cluster. None of the subjects in the control group had a presence of high-amplitude microsaccades in any of the tests in the VNG battery, resulting in 100% specificity. Our 3-test cluster potentially represents a quick, fairly sensitive and highly specific form of screening for patients suspected of sustaining a concussion. The presence of abnormal, high-amplitude microsaccades on VNG assessment is highly correlated with history of concussion and can be used diagnostically by health care professionals to confirm the presence of a suspected concussion (100% specificity in our 64-person control sample) but the absence of high-amplitude microsaccades does not rule out concussion (78% sensitivity with the 3-test cluster).

Introduction: The cerebellum follows a protracted development, continuing across childhood and adolescence. A recent study on functional connectivity in 150 children aged 8-18 years with a concussion revealed altered interhemispheric connectivity between the right supplementary motor area and the left cerebellum, reflecting "cortico-cerebellar uncoupling"(van der Horn et al., 2024). However, little is known about structural development of the cerebellum following a pediatric concussion. This study aimed at characterizing cerebellum structural development in young adolescents with a history of childhood concussion from the large population-based Adolescent Brain Cognitive Development (ABCD) Study (Casey et al., 2018).

Methods: The following baseline, 2-years and 4 years follow-up data from the ABCD 5.1 (Garavan et al., 2018) curated data release were used: 1) The Parent Ohio State TBI Screen-Short Modified Report (Bogner et al., 2017) to retrospectively identify children with no-TBI (n = 9,430 ; baseline mean age = 9.9 years; 4,721 [50.6%] females) and those with a concussion (i.e., head-neck injury with loss of consciousness ≤ 30 min or memory loss; n = 319; baseline mean age = 9.9 years; 133 [41.7%] females), and 2) right and left cerebellum grey matter (GM) and white matter (WM) volumes computed on T1-weighted images by the ABCD group. Scanner effects were controlled for using longitudinal-ComBat (Beer et al., 2020). Mixed effects models (Mirman, 2017) were constructed with lmerTest_3.1.3 package in R (2023.12.1) to explore group differences at baseline and on the rate of change between ages 10 to 14 years. Sex and parental education were included as covariates.

Results: There was no group effect on the developmental trajectories of the 4 cerebellar volumes. Compared to non-injured peers, children with concussion showed similar intercept (all p > 0.3) and slope (all p > 0.24) with a significant increase of WM volumes (Estimates [p-value]; Right = 13.3 mm3 [4.74e-05]; Left = 12 mm3 [5.74e-05]) and no significant change in GM volumes (Estimates [p-value]; Right = 5 mm3 [0.3]; Left = 3.1 mm3 [0.4]). There was a significant effect of sex and education on both intercept and slope for the 4 metrics (all p < 0.02). Girls showed lower WM and GM volumes than boys at baseline and slower increase over time (all p < 2e-16). Higher level of education was associated with larger WM and GM volumes at baseline (all p < 2e-16) and faster increase over time.

Conclusion: This study suggests that the structural development of the cerebellum between ages 10 to 14 years follows similar trajectory in young adolescents with and without concussion. However, cerebellum development was dependent on sex and parental education. Further explorations, notably on the group*sex interaction and on brain connectivity using diffusion MRI, will be conducted to fully understand these findings.

Rehabilitation is critical to facilitating recovery after traumatic brain injury (TBI). However, there is currently limited information on rehabilitation among individuals with TBI who experience homelessness. A scoping review was conducted to explore the extent to which rehabilitation, including the types of rehabilitation interventions, are available to, or used by, individuals experiencing homelessness and TBI. Electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health), grey literature, and peer-reviewed articles that met predetermined eligibility criteria were systematically searched. Qualitative content analysis and a descriptive numerical summary of extracted data were conducted. Fifteen peer-reviewed articles and three grey literature reports described interventions for individuals experiencing homelessness and TBI (N=4), rehabilitation for individuals experiencing homelessness without specific inclusion criteria for TBI (N=11), and rehabilitation interventions without specific inclusion criteria for TBI or homelessness (N=3). The following opportunities to advance rehabilitation for individuals with TBI who experience homelessness were identified: (a) screening for TBI, (b) conducting cognitive and functional assessments, and (c) tailoring interventions with multidisciplinary teams. This review also highlighted an urgent need to provide structured education and training for healthcare professionals regarding TBI and conduct research that considers the rehabilitation needs of diverse individuals experiencing homelessness and TBI.

Traumatic brain injury (TBI) is disproportionately prevalent among individuals who intersect with the criminal justice system (CJS). To date, there is limited information on the extent to which rehabilitation is available to, or used by, individuals with TBI who intersect with the criminal justice system. A scoping review was conducted to address this knowledge gap. Electronic databases (MEDLINE, Embase, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Proquest Nursing and Allied Health), relevant organizations’ websites, and reference lists of eligible articles were systematically searched. Twenty-two peer-reviewed articles and two grey literature reports met the predetermined eligibility criteria. A descriptive numerical summary and qualitative content analysis were conducted to understand the availability and extent of rehabilitation for individuals with TBI who intersect with the CJS. Existing rehabilitation programs are already serving individuals with TBI with a history of CJS involvement. However, TBI and/or CJS are rarely considered or acknowledged in rehabilitation interventions. The following opportunities to advance rehabilitation for individuals with TBI who intersect with the CJS were identified: (a) TBI screening, (b) education on TBI within CJS settings, and (c) linkages to the community to support continuity of care. This review also highlighted an urgent need to integrate sex, gender, and other intersecting factors into research and the rehabilitation process to enable timely and appropriate rehabilitation and continuity of care for diverse individuals with TBI who intersect with the CJS.

Background: Blast traumatic brain injury (bTBI) is a series of complex mechanisms which is poorly understood due to 1) our incomplete knowledge of blast mechanism on the brain and other organs and 2) lack of effective treatment strategies. bTBI outcomes are often complicated by excessive bleeding or severe internal hemorrhage resulting in hemorrhagic shock (HS), depletion of cellular ATP, cell death, and multiorgan failure. Several clinical studies demonstrated that males have higher mortality rates and TBI complications than females. Estradiol reduces mitochondrial dysfunction by enhancing neuronal survival during periods of cellular stress through increased ATP production while promoting mitochondrial antioxidant enzymes. Therefore, utilization of estradiol in male rats with combined bTBI + HS is a novel avenue to examine its possible neuroprotective and mitochondrial mechanisms.

Method: Pre-clinical rat model of combined njury was generated in adult male rats by subjecting them to either 1) three repeated blast exposures of 20 PSI without HS or 2) blast + HS. Post-injury intravenous fluid resuscitation during the pre-hospital phase (T60-120) with β-Estradiol 3-sulfate sodium, 1 mg/kg body weight in 0.9% NaCl @ 5 ml/kg/hr. or normal saline (served as control) was used. Blood collected at baseline, T60 (after HS with or without blast), and T180 (end) was analyzed for blood chemistry, acid-base balance, metabolites, and mitochondrial complex I activity.

Results: An increased base deficit, plasma lactate, acidic pH <7.3, and depletion of mitochondrial complex I activity compared to baseline in all injured animals. The primary mechanisms of combined bTBI and HS were due to both lactic-acidosis and mitochondrial damage. Compared with normal saline, estradiol treatment significantly improved the acid-base imbalance but did not improve the depletion of complex I activity following bTBI with or without HS.

Conclusions: Complex 1 activity and plasma lactate can be used as a predictive systemic marker of the severity of bTBI. Additionally, estradiol’s buffering effects can correct the acid-base balance without improving the mitochondrial damage. In addition to estradiol, other treatments targeted at mitochondrial damage might improve blast injury outcomes.

Background: Reported symptoms and experiences after sport-related concussion can be debilitating and vary dramatically. Research including the patient/student-athlete voice is needed to enrich our understanding of concussion management, rehabilitation, and recovery. Our understanding of return to academics and play decision-making after concussion among athletes is limited to youth or professional age groups, less is known about college-aged athletes in the United States.

Objective: Our objective was to explore how Division I collegiate varsity athletes experience recovery after sport-related concussion, as they manage their diagnosis, symptoms, and return to academics and return to play decision-making.

Methods: We conducted semistructured interviews with undergraduate student-athletes at a Division 1 University in the United States between October 2022 and May 2023 who had experienced at least one diagnosed sport-related concussion as a varsity athlete, inclusive of recently graduated alumni. We analyzed interview data using a modified framework method. We created a post-injury-recovery-return model and we summarize participant experiences in the context of these key moments over time.

Results: Interviews were conducted with 22 student-athletes (women, 59.1%; White, 77.3%; 27.3% Sophomore year) representing 15 sports teams. The majority of respondents had experienced at least one concussion prior to their varsity athletics concussion. Respondents reflected on four key moments in their experience of recovering from a concussion: (1) immediately post-diagnosis, (2) during recovery, (3) making decisions about returning to sport and academics, and (4) returning to sport and academics. We identified the importance of managing expectations, previous concussions, and emotions on recovery and return-to-academics and sport decision-making. We also found these experiences were shaped by the social environment and key actors (coaches, teammates, family members, friends and the University context).

Conclusion: Our findings indicate that experiences after concussion are influenced by factors including expectations for recovery, managing symptoms, and navigating decision-making, and by relationships and the social environment. Systems to improve communication between athletics and academics are needed to support the recovery of college athletes while minimizing disruption. Additionally, considerations of an athlete’s social network and collegiate environment should be the subject of future research and inform the development of new treatment and management guidelines for concussion.

Introduction: Goal setting is essential in rehabilitation after an acquired brain injury (ABI), as it encourages active involvement in recovery. At Center Naprej (CN), a goal-oriented rehabilitation approach allows users to personalize their recovery by setting goals in areas such as health, work, emotions, and social relationships. This individualized focus increases motivation and commitment, leading to better physical functioning and overall quality of life (QoL). Research shows that goal-oriented rehabilitation contributes to greater independence, improved functionality, and better emotional and social well-being—critical for long-term recovery success (Siegert&Taylor, 2004; Wade, 2009; Von Steinbuechel et al., 2010).

Objectives: To analyse the importance of goal setting in long-term rehabilitation and examine the relationship between goal achievement and QoL after ABI.

Methods: The study consisted of two parts. The first part (2019–2023) analysed the significance of goal setting using a two-level goal taxonomy linked to the "Wheel of Life" tool, where users assessed 10 life areas. General goals (first-order) and specific goals (second-order) were categorized and analysed. In the second part (2023-2024), the study expanded to explore the connection between goal achievement and quality of life after ABI. Participants: The first part: 62 users from CN (15 women, 47 men, M-age=54.87). The second part: 47 users (12 women, 35 men, M-age=55). Measurements: Quality of Life after Brain Injury - QOLIBRI; Self-evaluation of Rehabilitation Goal Achievement (CN, 2019).

Results: We examined 253 general and 1,122 specific goals. Users most frequently set goals in the areas of Knowledge/Work (36% of general and 35% of specific goals) and Health (28% of general and 46% of specific goals). Results showed that 48% of general goals improved in evaluations over the years, with the average evaluation increasing from 5.49 in 2019 to 6.66 in 2023 for general goals, and from 5.18 to 6.75 for specific goals. Additionally, 33% of general and 27% of specific goals were consecutively evaluated for five years, indicating long-term goal pursuit. In the second part, a positive trend was found between goal achievement and QoL, though the correlation was not statistically significant (p=0.058), but there was a medium effect size (η2=0.083).

Conclusions: The study showed that goal achievement in long-term rehabilitation plays a role in QoL after ABI. Users at CN mainly set goals related to Knowledge/Work and Health, reflecting a desire to restore functionality and well-being. The pursuit of long-term goals suggests that commitment to these goals is essential for successful rehabilitation. Although the correlation between goal achievement and QoL was not statistically significant, we´ve got a medium effect size. The trend indicates that higher goal achievement is associated with better QoL. This highlights the importance of setting realistic, achievable goals that provide a sense of progress and success in the rehabilitation process.

Resilience on the Court: Return to Competitive Basketball After Severe Traumatic Brain Injury

Case Diagnosis: A 17-year-old male involved in a motor vehicle collision (MVC) sustained a moderate to severe traumatic brain injury (TBI) and successfully returned to competitive basketball six months post-injury.

Case Description: A 17-year-old male presented to a Level 1 trauma center following an MVC, with an initial Glasgow Coma Scale (GCS) score of 12. Head imaging revealed a grade 2 diffuse axonal injury and a left frontal hemorrhagic contusion. His hospital course was complicated by severe agitation, which gradually resolved. The patient was eventually discharged home.

Two months after discharge, he visited the outpatient TBI clinic, seeking clearance to return to competitive basketball. At that time, he had achieved a full recovery to his pre-injury physical and neurological baseline. He had resumed school with high academic performance, regained his ability to drive, and returned to non-contact sports. A follow-up CT scan six months post-injury showed no residual hemorrhage, and a comprehensive neurological exam was normal. Based on these findings—his full return to premorbid baseline, successful reintegration into daily life, and normal neuroimaging—the patient was cleared to resume competitive basketball. He was counseled extensively on the potential risks and benefits of returning to sport post-TBI.

Discussion: Emerging data and clinical experiences reveal that young patients with moderate to severe TBI can make remarkable recoveries, challenging previous assumptions about long-term impairment. However, there are currently no specific guidelines for returning to competitive sports following moderate to severe TBI. This case offers insight into the decision-making process clinicians may use when evaluating patients for a return to high-level physical activity after such injuries.

While this patient demonstrated full neurological and cognitive recovery, further research is needed to define the criteria for assessing readiness to resume competitive sports. Factors such as injury severity, cognitive and neurological recovery, time elapsed since injury, and repeat neuroimaging results may all play crucial roles in this decision-making process. Additionally, the benefits of promoting physical activity and social reintegration must be weighed against the potential risks of re-injury.

Conclusions: No standardized guidelines currently exist for determining when it is safe for patients with moderate to severe TBI to return to competitive sports. As full physical and neurological recoveries become more common in young TBI patients, individualized assessments—including cognitive status, neuroimaging, and recovery milestones—should guide decision-making. Developing clear guidelines for return to sport will be essential in the future to ensure optimal outcomes for TBI patients.

Introduction: Psychological readiness to return to sport (RTS) refers to an athlete’s mental and emotional preparedness to confidently resume sport participation following injury. However, it remains unclear if there are sex differences in psychological readiness to RTS among concussed collegiate student-athletes and if this changes throughout concussion recovery.

Purpose: To investigate sex-based differences in psychological readiness to RTS among collegiate student-athletes within 5 days of sustaining a concussion (Initial visit) and at time of RTS visit.

Methods: Collegiate student-athletes were administered the Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale at Initial and RTS Visits. Higher total scores for the I-PRRS (22 items summed; Likert scale 0 (low confidence) to 100 (high confidence)) are associated with greater confidence for RTS. A 2 sex (male, female) x 2 time (Initial, RTS) analysis of variance (ANOVA) was conducted to determine differences on I-PRRS scores (p < .05).

Results: Approximately 32 Division I student-athletes (Female= 16, age= 20.35 ± 1.68yrs) who sustained a concussion were included in this exploratory study. Results revealed a significant effect of time (F(1, 31) = 40.04, p < .001), with scores improving from Initial Visit (M = 73.84) to RTS (M = 95.20). There was no significant effect of sex (F(1, 31) = 3.09, p = .089) for male (M = 87.64 ± 18.63) and female (M = 80.78 ± 18.01) concussed student-athletes. Additionally, there was no significant interaction between time and sex (F(1, 31) = 1.53, p = .225), indicating that the improvement in scores over time was similar for both sexes.

Conclusion: In conclusion, the results indicate a significant improvement in psychological readiness from the Initial Visit to the RTS assessment, highlighting the positive trajectory of recovery among concussed collegiate student-athletes. However, the lack of significant effects related to sex suggests that both male and female student-athletes experience similar levels of psychological readiness as they progress through concussion recovery. These findings underscore the importance of considering time as a critical factor in rehabilitation, while also indicating that interventions could be equally effective for all sexes. Further research should examine additional variables that could influence psychological readiness to RTS.

It is estimated that approximately 19,000 people experience an acquired brain injury (ABI) in Ireland each year, which impacts significantly on quality of life for the person and their families. International research indicates that people with an ABI who access neurorehabilitation services earlier have better outcomes than those who access services later. Unfortunately, the lack of community-based transitional rehabilitation services for people with an ABI leaving hospital often results in many people being placed in inappropriate placements in nursing home facilities or being discharged home without supports. Acquired Brain Injury Ireland is a leading provider of community-based neurorehabilitation for people with an ABI in Ireland. In 2007, ABI Ireland, in partnership with the Health Service Executive, established the first transitional rehabilitation service for adults with an ABI in the Northwest of Ireland. The service provides short-term high intensity neurorehabilitation to four individuals at any one time and provides a rehabilitation pathway from hospital to home. This model focuses on enhancing the independent living skills of participants, by supporting the individual and their families to understand the impact of the ABI, and through the development of individualised neuropsychological and cognitive rehabilitation programmes. Support is provided in the service Monday to Friday, with individuals returning home to their families / community at weekends, to ensure transfer of their skills and strategies to their home environment. Rehabilitation is provided by Neuropsychology, Occupational Therapy and Rehabilitation Assistants on site and referrals can be made for Speech and Language Therapy and Physiotherapy. Upon discharge, a community-based rehabilitation team can continue to provide essential supports as the individual transitions home full-time. The model also allows for participants who previously accessed the transitional rehabilitation service to access a readmission to address new goals or prevent deterioration. Since its establishment, the transitional rehabilitation service has supported over 250 people with an ABI and their families. With 85% of admissions to the service coming from the acute hospital, the service provides a timely and direct route for ongoing rehabilitation before the person returns home. The average length of time from injury to admission into the service is 17 weeks; therefore, optimising the potential for rehabilitation and recovery. Most people who have accessed the service have successfully been discharged home within 12 weeks. From 2022 – 2023, data analysis of aggregated Mayo-Portland Adaptability Inventory – 4 outcomes demonstrated that participants (n=10) who accessed the service achieved a reduction in their limitations across all subsets; abilities, adjustment and participation. Given the success of the model, it is proposed that it be replicated to meet the needs of more adults with an ABI in Ireland.

Background and Aims: Fatigue is a distressing symptom in many neurological conditions. Patients describe that symptoms tend to fluctuate throughout the day and may exacerbate from one moment to the other. This pilot study aimed to evaluate the feasibility of real-time monitoring for mapping the temporal dynamics of fatigue in daily life of adults with cerebral palsy (CP).

Methods: A prototype 20-item survey, Fatigue in Daily Life (FIDL), was designed for the assessment of momentary fatigue and its antecedents, consequences, and co-occurring symptoms. Data was collected ten times a day for seven consecutive days using the smartphone app, SEMA³. Semi-structured interviews were conducted with participants after real-time monitoring. Quantitative data were analyzed using mixed-effects models, in which observations (Level 1) are nested within days (Level 2) and persons (Level 3), to estimate the intraclass correlation coefficient (ICC) of the fatigue item. Qualitative data were analyzed to explore content validity of FIDL and acceptability of the sampling schedule.

Results: Ten adults with CP completed the study (no dropouts), six females (60%), mean age = 43.7 years, Gross Motor Function Classification System ranging from I to III. The average response rate on the repeated surveys across days was 75.5%. Eight participants (80%) responded to at least 50% of the surveys. Median completion time was 1.67 minutes. The ICC of fatigue was 0.04 for Level 2 (days) and 0.38 for Level 3 (persons), indicating that 4% and 38% of the variance is attributable to stable differences between days and persons, respectively. Thus, the remaining 58% of the variance is due to daily fluctuations in fatigue. Univariate regression analyses showed that energy (B = -0.86), sleepiness (B = 0.68), and exhaustion (B = 0.63) had the strongest association with fatigue. Seven participants (70%) reported they could express exactly ‘how they felt’ when completing the FIDL survey, and 80% reported that answering the survey was easy and manageable. Accordingly, 80% reported that the survey was not demanding or extensive to complete. Those reporting difficulties requested an open-comment field to elaborate on their experiences. Four participants (40%) reported that it was difficult to respond to all ten surveys per day, and 20% would prefer fewer surveys per day or fewer items per survey. The reasons for unanswered surveys were related to being busy at work, having a business meeting, or being engaged in sports or other activities, which prevented the participant from responding. The duration of the study was acceptable to all participants.

Conclusion: Fatigue is a dynamic symptom, and it is feasible for adults with CP to monitor fatigue using the FIDL survey. Pilot results inform the design of a planned study on the dynamics of fatigue across adults with CP and acquired brain injury.

Introduction: A substantial number of individuals report persistent memory difficulties following mild traumatic brain injury (mTBI), often affecting their quality of life. However, the pathogenesis underlying the persistence of these complaints remains controversial, making it difficult to establish tailored interventions for patients in need. Indeed, while it is recognized that neurobiological and psychological factors interact with objective memory difficulties, the exact nature of this interaction is still unclear (Hayes et al., 2016). Given that some researchers suggest that patients may develop a more negative perception of their memory after a head trauma, exploring the role of metacognitive change in the maintenance of memory complaints could help clarify this interaction (Kit et al., 2007).

Objectives: This longitudinal study will examine the effect of brain lesions (e.g. microlesions), objective memory difficulties, psychological factors on memory complaints, by exploring metacognition as a potential mediator in their long-term persistence.

Methods: Three matched groups of participants (n = 60 per group) will be recruited: mTBI, orthopedic injury (without TBI), and healthy controls. Participants will be assessed at two time points: the first during the acute phase (T1, within three months of the accident for both mTBI and orthopaedic groups) and the second approximately eight months later (T2 ; i.e., one year after the accident). Memory complaints will be measured through the Multifactorial Memory Questionnaire and the Autobiographical Recollection Test, while episodic memory will be assessed using a task based on the Experience Sampling Method (ESM). In this method, participants use a smartphone app to complete short questionnaires about their activities over the course of a week. Five of these recorded events will then be used to create a personalized memory task in which participants will be asked to describe these events in detail, allowing for an assessment of the richness and accuracy of their recalls. This task will also be used to explore metacognitive accuracy confidence judgments associated with event memories. A metacognitive accuracy change score between T1 and T2 will be calculated. Psychological factors such as catastrophic thinking, avoidance, endurance behaviors, depression, anxiety and PTSD will be assessed through different questionnaires. Finally, to examine brain damage, mTBI and control participants will undergo 7 Tesla fMRI scans. To investigate whether metacognitive changes occur after mTBI, general linear models will be run on metacognitive accuracy change scores with group as independent variable. Scores for which an effect of mTBI is observed will then be entered into mixed-effects model analyses with these different factors to determine their influences on long-term memory complaints. By shedding light on the relative importance of different factors that contribute to the persistence of long-term memory complaints, this study could help to develop more tailored interventions.

While stroke incidence is higher in the elderly, cases among adults aged 18 to 64 are rising. These young adults are more likely to experience mild strokes, usually recover faster with fewer motor and sensory impairments, and typically do not receive rehabilitation services. However, they may still experience hidden impairments, including cognitive deficits, psychological symptoms, and fatigue. These impairments often become more disabling when resuming everyday activities, such as work. Given the personal and social importance of work, understanding the challenges faced by young adults in returning to work after stroke is essential. Although a number of studies have looked at the process of return-to-work (RTW) post-stroke, none have examined the issues experienced specifically by this population. The aim of this qualitative study is to describe the RTW experience of young adults who experienced a mild stroke. Specific objectives were to 1) identify factors acting as barriers or facilitators to RTW, and 2) explore the use and needs of professional health services related to RTW. Participants were recruited from a larger study on cognition and participation after mild stroke. In-depth interviews (using a structured guide) were conducted in person or via videoconference with 13 adults who had experienced a mild stroke (77% women; mean age = 48, range = 36-61; mean time post-stroke = 17 months). All had full-time jobs pre-stroke and had attempted a RTW after stroke, including eight who returned progressively and five who returned fully. By the time of the interviews, eight had returned to their previous jobs without changes, two with adaptations, one switched to part-time with a different employer, one took on a new position, and one discontinued work. Interviews were analyzed thematically and factors related to RTW were coded into three categories inspired by the APC model of RTW post-stroke (Schwarz et al., 2018): the person, the workplace, and health services. Preliminary results suggest that person-related factors included stroke sequelae, personal characteristics, motivation, financial and social resources, assessment of readiness for RTW, life context, and coping strategies. Workplace-related factors included the nature of the job, implementation of work adaptations, communication with employers, and disability management. Health service factors included access to a medical RTW plan and follow-up, communication with medical teams, psychological support, support for physical recovery, and timing of services. Few participants accessed rehabilitation services, with most receiving care from medical teams or family doctors, while many sought private rehabilitation or mental health care. Participants expressed a need for adapted RTW plans (including sick leave, progressive RTW, and ongoing adjustments), readiness assessments, referrals for psychological support, and more information on stroke and RTW. Understanding these needs could improve service delivery, enhancing quality of life, recovery, and social participation for individuals with mild stroke.

Introduction: Brain injury can negatively influence a person’s capability to manage personal finances, with 30% to 70% of people self-reporting issues managing their finances after acquired brain injury (ABI). Yet, there is only one published intervention study addressing financial capability after ABI and no study about lower-cost financial capability products for adults living with ABI.

Objective: Our aims were to: (1) co-design an individualized low-cost financial wallet-card product and (2) explore the card’s acceptability, feasibility of use, outcomes of actual use, and ideas for improvements.

Methods: We conducted a pilot longitudinal qualitative intervention study. We included 10 adult participants living with ABI (n=7 female; age range: 28-74 years; ABI mechanism: n=7 traumatic, n=2 stroke, n=1 other; time since ABI range: 1-59 years). We co-designed a two-sided financial wallet-card with each participant; side one provided social-cues to guide others in providing individualized support in financial-related situations, and side two included personal financial management reminders. Participants could update their card during the study. We provided participants physical and electronic card versions and completed up to six individual interviews with each participant over 2-3 months. We analyzed interview transcripts using content analysis.

Results: Co-designed card content varied depending on participants’ needs and contexts. Five participants updated their cards during the study. Nine participants expressed general support and acceptance of the card at the start of the study and eight at the end of the study. Reasons for card acceptability included empowerment in the co-design process (n=8 participants) and feeling the card fit well into their daily life (n=8). Negative feelings for acceptability were not liking an element of the design (n=6) and personal worries about potential negative reactions of others (n=4). These continued worries were noted as a barrier to using the social-cues side of the card at different times and in some contexts (n=9). All participants noted self-efficacy or cognitive challenges with initiation or memory as barriers to card feasibility of use. Participants identified multiple feasibility of use facilitators, including card convenience, flexibility, versatility, and accessibility (n=9). Eight reported positive use outcomes during the study. Positive outcomes reported included personal feelings of empowerment and validation (n=9), providing information to others in a way that positively changed others’ behaviours (n=8), and changing their own financial thoughts and behaviours (n=9). Seven participants planned to continue to use the card after the study. Card improvements identified included changes to card materials (n=2), better publicly known organizational affiliations (n=3), and improvements to electronic card access (n=3).

Conclusions: Our results provide initial effectiveness evidence for a co-designed financial wallet-card, which could be a cost-effective and scalable intervention product. Enhancing card materials quality and partnering with a more publicly known organization could improve perceived card legitimacy and use.

Background: Childhood stroke, occurring between 28 days to 18 years of age, encompasses two main categories: arterial ischemic stroke (AIS) and hemorrhagic stroke (HS). This study aims to investigate the motor and functional performance of children with childhood stroke in Hong Kong, as well as to examine the factors that are related to poorer functional status.

Methodology: This preliminary cross-sectional study recruited twenty-four children and adolescents (15 males, 9 females) who had experienced childhood stroke, comprising 11 cases of AIS and 13 cases of HS. Participants, aged between 6 and 18 years at the time of assessment, were excluded if they had prematurity, genetic disorders impacting the nervous system, Hypoxic Ischemic Encephalopathy, Cerebral Palsy before the initial stroke event, or traumatic brain injuries. The mean age of participants was 13.3 years (SD 3.5 years), with the mean age of stroke onset at 6.4 years (SD 5.8 years). Motor and functional performance were assessed using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2), and the Functional Independence Measure for Children (WeeFIM), respectively.

Results: This study examined the motor performance of participants using the BOT-2 assessment. A significant portion of participants demonstrated below-average performance (-1.0 to –2.0 SD) in total motor composite (62.5%), fine manual control (54.2%), and manual coordination (83.3%). Poorer motor skills were associated with worse functional outcomes (r=.584, p=.003). Additionally, poorer strength and agility were associated with worse self-care (r=.563, p=.005), transfers (r=.493, p=.017), locomotion (r=.511, p=.017), and cognition quotients (r=.445, p=.033).

Conclusions: We examined the motor performance of childhood stroke survivors and identified associations between motor components and various self-care domains in children. In our cohort of childhood stroke survivors, we observed a higher incidence of deficits in manual coordination. Notably, impairments in strength and agility were more significantly correlated with challenges in daily functioning skills. These results highlight the intricate relationship between motor abilities and functional outcomes in children post-stroke, emphasizing the need for individualized interventions to address specific motor domains for optimizing functional independence.

Purpose: In order to optimize recovery from concussion, promote return to activity, and prevent medical complications, best practice guidelines have been developed and implemented that emphasize a gradual return to activity (Patricios et al., 2023). Despite the importance of best practice guidelines, literature suggests that physicians may have difficulty translating best practice guidelines into clinical practice (Arbogast et al., 2013) and may not consistently communicate best practice return to activity guidelines to patients and families (Seabury et al., 2018; Weerdenburg et al., 2016). Education regarding return to activity following concussion that is developed from the perspective of an occupational therapist has the potential to offer a unique perspective that might not traditionally be included in medical school curricula. The purpose of this study was to explore the effects of an education training module on medical students' knowledge and perspectives of concussion best practices for return to activity and the role of occupational therapy.

Methods: Medical students at a private Osteopathic Medicine School participated in an educational training seminar on best practices for return to activity following concussion and the role of occupational therapy. A pre and posttest with open and closed ended questions were used to evaluate the effects of the training program. A paired t test to determine if there was a statistically significant difference on the Concussion Knowledge assessment following the educational seminar.

Results: There was a significant difference in the scores for pre-knowledge assessment score (M = 8.13, SD = 1.76) and post-knowledge assessment total score (M = 10.68, SD =1.9); t(55) = -8.5, p = <.001. Medical students demonstrated improved scores on post-test knowledge assessment of concussion and best practices related to return to activity and reported that they were more aware of the importance of gradual activity, aerobic exercise, and interdisciplinary collaboration, including referral to occupational therapy.

Conclusion: The results indicate that an educational training on concussion, gradual return to activity, and the role of occupational therapy may improve medical students' knowledge of best practices for management of concussion.

References: https://docs.google.com/document/d/1jVsvXo2-Y50fOlfzege71UQtzXylVzsk0Dof2d3D44k/edit?usp=sharing

Five years into a partnership between CONNECT Communities and Hamilton Health Sciences, a 2024 Service Evaluation has revealed compelling outcomes on both a human and a health system level.

Hamilton Health Sciences, the legacy Hamilton Niagara Haldimand Brant LHIN, and a collection of acquired brain injury service providers collaborated on the identification of a gap in the service continuum in Ontario and produced an RFP to solicit proponents to fill that gap.

CONNECT was awarded that contract, and, in partnership with Hamilton Health Sciences, opened its doors in 2019.

As part of the planning of this service, the legacy LHIN asked HHS and CONNECT to evaluate the service after four years. The teams put their heads together to create a scorecard to gather data on a human and system level. A service evaluation was produced to see if the gap that had been identified was being filled.

The Service Evaluation revealed:
1. Outstanding personal outcomes for individuals after brain injury and stroke moving back to community;
2. Significant system improvement contribution in the Ontario Health West Region;
3. Value for money demonstrated by a powerful Return on Investment (ROI), break-even point and long-term health system savings; and
4. Extensive contribution and alignment with the Ontario Ministry of Health and Ontario Health's Strategic Priorities 2023/'24.

CONNECT was founded in British Columbia in 1993 to create a better pathway for people after brain injury and stroke. CONNECT’s Life Redesign Model is intentionally different and focuses on participation in real life and meaningful activities in a supported home environment. People move to CONNECT where they build their life with the right supports and approach. CONNECT's Life Redesign Model is deemed Leading Practice by Accreditation Canada and is characterized by the following:
• A culture of personal accountability, supported risk taking, social capital and meaningful community participation;
• Services planned around what the person wants in life, where participation in relevant life situations drives the individual's goals;
• Service plans leverage neuroplasticity by pursuing goals and rewiring in real-life, non-institutional settings; and
• A "doing-with" coaching approach with blended job roles and a multi-professional coaching team.

The outcomes in Hamilton tell a story that could change the trajectory for individuals and health regions across the country, including a move-home-rate of 70%.

Patti Flaherty, CEO of CONNECT and Kim Young, Director, Regional Rehabilitation and Integrated Stroke at HHS will present these and other compelling findings from the Service Evaluation.

Background: Pharmacotherapy is a common practice for treating the various sequelae associated with traumatic brain injury (TBI). For example, psychotropic medications may be used to inhibit the psychological, cognitive and/or somatic impacts resulting from the injury, and several drugs may be prescribed at once (polypharmacy). However, the current literature does not provide an overall picture of the long-term use of various medications after TBI.

Objective: The objectives of this study were to 1) Describe participants' medication use (therapeutic classes, number, level of polypharmacy) over the first four years post-TBI; 2) Compare use of certain types of medication according to TBI severity, gender and age.

Methods: Participants were 491 adults (ages 18-65) with mild to severe TBI recruited from two Level 1 trauma centers (Hôpital de l'Enfant Jésus, Hôpital Général de Montréal). They were assessed at 4, 8, 12, 24, 36 and 48 months post-TBI and were asked to describe their medication intake during a structured interview. The different medications reported were classified according to the Anatomical Therapeutic Chemical (ATC) classification system. The polypharmacy level classification of Masnoon et al. (2017) was used: no polypharmacy, minor polypharmacy (2 or 3 medications), moderate (4 or 5), or major (> 5). All prescribed medications reported were considered in calculating this index, even if the medication was related to a comorbidity (e.g., medication to control blood pressure).

Results: Descriptive analyses show that the most common therapeutic classes of medication used at 4 months post-TBI were analgesics (29%), psycholeptics (22%), psychoanaleptics (20%) and anticonvulsants (20%). These therapeutic classes remained the most frequently observed over time. The total number of medications decreased significantly (p < .05) with time (2.5 molecules at 4 months vs 2.3 molecules at 48 months). Around half (49%) of participants had no polypharmacy while around 25% had minor polypharmacy, 12% had moderate polypharmacy and 14% had major polypharmacy in the four years following the accident. Chi-square tests showed that compared to participants with moderate-severe TBI (p < .05), participants with mild TBI used more analgesics at 24, 36 and 48 months. Men (p < .05) used more psycholeptics than women at 24 months, and women (p < .05) used more psychoanaleptics than men at 48 months. Significant age differences were also observed.

Conclusions: Medication use and polypharmacy are frequent post-TBI and varies according to severity of the injury, gender and age. Future research should explore the potential impact of polypharmacy on psychological and cognitive functioning post-TBI. This knowledge could eventually help guide the development of more appropriate pharmacological plans for this population.

Background: Sports-related concussions pose significant diagnostic challenges. This condition can lead to various physical, emotional, and cognitive symptoms, including deficits in the visual system. Identifying and addressing these dysfunctions promptly after concussion is crucial to ensure safe return to play. The visual system being heavily involved in sports, it is essential to highlight the tools used for its assessment, thereby equipping healthcare professionals effectively.

Objective: The main purpose of this study is to expose, through a systematic review, visual assessment tools available in the literature used in the context of acute sport-related concussion evaluation.

Methods: This review was registered in PROSPERO on December 14, 2023 (CRD42023487769). Documents were identified from the Medline, CINAHL, SportDiscus, and Academic Search Complete databases. To be included, peer-reviewed articles had to (1) be written in English or French, (2) be published between 2009 and 2023, (3) take place in a sports context, (4) involve adult and/or pediatric athletic populations, and (5) assess the visual system (completely or partially) within 0 to 7 days after a sport-related concussion. Document selection occurred on Covidence platform, and risk of bias assessments were conducted using Joanna Briggs Institute quality assessment tools. These steps were completed by three distinct reviewers.

Results: Eighteen articles were included in this review, involving a total of 7,702 athletes with a mean age of 19.2 years old. A variety of amateur to elite sports were represented. Among these, 2,574 sport-related concussions were assessed using five distinct visual assessment instruments: Vestibular/Ocular Motor Screening (VOMS) (n=12), King-Devick (n=4), King-Devick combined with eye tracking (n=1), Monocular Eye Tracking System (n=1), and Mobile Universal Lexicon Evaluation System (MULES) (n=1). Overall, assessments using these tests indicated worsening scores following acute sport-related concussions. VOMS, the most studied tool in this review, demonstrates great sensitivity and specificity for diagnosing concussions and the potential to predict a longer recovery when lower scores are observed.

Conclusions: This review is limited by the small sample size for other tools than VOMS. Additionally, the evidence level of the included articles was somewhat low. In summary, this review contributes to advancing the scientific understanding of the available tools for assessing the visual system in the context of post-concussion visual dysfunction in sports.

Objective: The aim of the study was the systematic exploration of point-of-care biomarkers as diagnostic indicators for the detection and exclusion of mild traumatic brain injury (mTBI) in an Emergency Setting using Eye-Tracking and Virtual Reality (ET/VR) technology. The primary target group included patients who had suffered an acute trauma to the head and presented within 24 hours to the emergency department. The aim was to investigate oculomotor biomarkers for their suitability in diagnosing mTBI in a consecutive cohort of patients exposed to external force and to test the practicality of using ET/VR goggles in an emergency department.


Methods: The BG Unfallkrankenhaus Berlin and the BG Klinikum Hamburg participated in this explorative prospective single-arm accuracy study. In the emergency department, patients with suspected mTBI were included and examined using ET/VR goggles. All further steps followed clinical routine (e.g., decision on hospital admission, imaging diagnostics). The clinical diagnosis of mTBI was made after treatment completion and blinded to the results of the index test (examination using ET/VR goggles) through a clinical synopsis by two independent clinical experts. The diagnosis was based on all clinical, neurological, neurofunctional, neuropsychological, and imaging findings. Routine trauma and neurological history, examination, and findings were recorded for each case. All statistical analyses were conducted with exploratory intent.


Results: The use of ET/VR goggles was found to be predominantly unproblematic. Two of the 52 analyzed parameters were statistically distinguishable from random decision-making. No differences in oculomotor function were found between the two subgroups.


Conclusions: No correlations were found between the parameters recorded with the VR goggles and the detection of mTBI. Currently, the use of VR goggles for diagnosing mTBI in an ER setting cannot be recommended.

Student clinicians often encounter a disconnect between course-based learning and clinical contexts. This happens when clinicals occur apart from course-based learning. Course embedded clinical experiences (CECEs) address this gap (Hoepner, 2018; Hoepner & Sather, 2020; Hoepner & Zigler-Miller, 2024). CECE follows a cycle, introducing a classroom approach, followed by a related clinical experience supported by an instructor and reflection, additional instruction, another clinical engagement and ongoing reflection as the instructor reduces support. This follows a guided apprenticeship model (Donaldson, 2015; Feeney & Lamparelli, 2002; Hautemo & Dalvit, 2016; Wilson et al., 2017). The instructor models their thinking in-the-moment and during guided class time reflections. Think-aloud sand models by an experienced clinician support deeper reflections by novice, student-clinicians (Ginsberg, Friberg, & Visconti, 2016). Students in a graduate-level, speech-language pathology counseling course (n = 36) demonstrated improved self-efficacy and skill (Hoepner & Zigler-Miller, 2024). With the instructor, they co-delivered motivational interviewing sessions to three clients each semester. The CECE format enabled them to make gains in authentic counseling skills with the support of the instructor and peers.

Methods: The current study examined graduate-level, acquired cognitive disorders course outcomes in a speech-language pathology program. Thirty-seven students (18 in 2022, 19 in 2023) facilitated a modified TBIconneCT social communication and communication partner training program (Hall et al., 2024; Rietdijk et al., 2020; Rietdijk et al., 2019). In 2022, 16/18 participated in the follow-up study, while 19/19 participated in 2023 (n = 35). TBIconneCT is a 10-week, manualized treatment program that incorporates psychoeducation, video modeling, and collaborative goal setting. Post-intervention, students completed an 11-question structured reflection (McAllister & Lincoln, 2004). Student reflections were qualitatively coded using Braun and Clarke’s (2021) thematic analysis.

Results: Instructor observations revealed that all students became proficient in delivering the manualized, TBIconneCT intervention. The rate at which they reached proficiency varied substantially across clinicians, but all achieved this benchmark by week 8 or earlier. It was feasible for all students to implement the program given scripting suggested in the treatment manual and PowerPoint slides. Students were allowed to make small changes in wording to address dialectical and personal differences. Qualitative analyses identified several themes about student learning experiences. This included a “better understanding of individuals with TBI’s lived experiences”, “no two TBI experiences are the same”, “making a connection between academic learning and real-life interventions and people”, and “increased confidence in clinical and counseling skills.”

Conclusions: The scripted, manualized TBIconneCT intervention program made it possible for novice clinicians to successfully implement the intervention. While fidelity was not measured directly, students were observed to fully adhere to the intervention script with changes approved by the course instructor. Future directions include finalizing the 2023 analysis and making adjustments to the TBIconneCT CECE implementation.

Patients Discharged From The Intensive Care Unit (ICU) Experience Persistent Impairment in Physical, Cognitive, and Mental Health, Which Has Been Termed Post-Intensive Care Syndrome (PICS). The Brief Cognitive Assessment Tool (BCAT) is a Screening Test For Cognitive Dysfunction That is Unique From Other Tools in its Emphasis On Contextual Memory And Executive Control Functions. Abnormal Scores of Less Than 44/50 are Validated Predictors of Mild Cognitive Impairment and Dementia, As Well As Functional Deficits. Our Work is the First Reported Use of the BCAT For Evaluation of Cognitive Function in the Post-Critical Illness Setting.
This Was a Retrospective Single Center Study at an Academic Tertiary Care Center of Adult Survivors of the Medical or0 Surgical ICU With a Diagnosis of Polytrauma, Sepsis, and/or Respiratory Failure and ICU Stays >72 Hours Who Completed Outpatient BCAT Testing Administered By a Trained Clinician at a Multidisciplinary PICS Clinic Visit Between May 2023-November 2023. Data Regarding Pre-Admission Characteristics and Functional Status, Medical History, Hospital Course, BCAT test Results, and Symptoms at Follow-Up Were Collected Via Retrospective Review of the Electronic Health Record. Two Sample T-Test and Wilcoxon Rank-Sum Test Were Used to Compare Parametric and Non-Parametric Characteristics.
A Total of 30 Patients Were Included (13 Medical and 17 Surgical). Eighteen (60%) Patients Had an Abnormal BCAT Score (<44), Though Only 12 (40%) Reported Subjective Memory or Concentration Difficulty. Patients With An Abnormal BCAT Were Older (61±15 vs 44±14 Years, p=0.004) and Less Likely to Be Working Prior to Hospitalization. There Were No Significant Differences in Co-Morbidities, Baseline Functional Status, Lengths of Stay, SOFA Score, Type or Duration of Cardiopulmonary Support, Analgosedation Exposure or Duration, Delirium Positive ICU Days, or Time From ICU Admission to Initial BCAT Test.
The BCAT is a Useful Tool For The Multidimensional Assessment of Cognitive Function in Survivors of Critical Illness and is Easily Administered in an Outpatient Setting. Most Patients Demonstrated Abnormal BCAT Performance but Did Not Consistently Self-Report Symptoms of Cognitive Impairment. Differences in Overall Test Results Appear To Be Driven By Performance Variations in Subtests of Visuospatial Skills, Recall, and Memory

Purpose: This study provides a comprehensive analysis of the complexities in friendships among people with traumatic brain injury (PwTBI). Here, friendships are broadly defined to include social friendships, as well as marital and spousal relationships. Previous research has explored how communication and identity changes after acquired brain injury (ABI) can impact the quality and quantity of spousal and social friendships. However, these studies do not fully depict the complexity of relationships. This study aims to address this gap by investigating the changes in the relationships of PwTBI in order to deepen our understanding of the complex effects of ABI on friendships.

Methods: This investigation included 34 individuals from three different datasets. The Sydney Psychosocial Reintegration Scale - 2, which includes quantitative and qualitative questions about relationships before and after ABI, was administered to all participants across the three data sets. A mixed-methods approach was used to triangulate both quantitative and qualitative data related to friendships and spousal relationships.

Results: Every participant indicated changes in some relationships, such as, divorce (24%), marriage struggles (27%), lost friends (30%), changes in closeness (36%) and social network changes (42%). Interpretative phenomenological analysis identified six main themes including: families were the most stable relationships, changes in marital and romantic relationships, shifts in close friendships, changes in work relationships, distant and virtual friendships, and the formation of new support group friendships. Appraisal analysis indicated that the most evaluative language focused on significant other relationships, and that the quantity of friendships were impacted by the ABI, but often individuals maintained some high-quality relationships with close friends and family.

Conclusions: ABI results in changes in friendships and decreased social networks contributed to increased reliance on family members for support. Factors including changes to vocation, geographical location, and communication were all associated with changes and often losses of friendships. Re-engagement in meaningful activities is connected to reestablishing and maintaining friendships. ABI support groups and other community groups, online or in person, are a viable way to support quality friendships. There is a continued need to evaluate specific types of relationships to guide education of communication partners.

Purpose: This framework for social, cognitive-communication assessment and intervention “the Social Communication Implementable and Applicable Lens (SoCIAL)” is intended to make social communication assessment and intervention efficient and accessible to practicing clinicians, across a variety of service provision contexts (acute care, outpatient etc.). The framework draws on the best practice recommendations, theories and models outlined in the available literature (e.g., Byom et al., 2020; MacDonald, 2017, Togher et al., 2023). The literature has long highlighted the need for a culturally responsive and individualized approach to assessment and intervention of communication, and this framework is designed to account for, document and address identity, demands, abilities and environment in the communication context of interest, as it applies to quality of life.

Method: The SoCIAL Model (Keegan et al. 2023) was initially developed in response to the need for a framework that could guide clinicians working with those who experienced social communication difficulties after TBI. This model was further modified based on feedback solicited from expert researchers and clinicians at a variety of conference meetings including the 2023 14th World Congress on Brain Injury, Dublin Ireland, 2023 American Speech-Language-Hearing Convention, Boston, MA USA, 2024 International Cognitive Communication Disorders Conference, Chapman, CA, USA. The authors incorporated this feedback and worked on developing an updated clinically applicable framework (Keegan et al., In Press).

Results: This poster presents the framework and includes clinically applicable recommendations for a package of accessible, critically appraised and recommended tools that clinicians may feasibly implement in their assessment of social communication. Assessment recommendations draw on best practice recommendations and literature (Morrow et al, 2020; Sohlberg et al., 2019; Steel & Togher, 2019; Turkstra et al., 2005), and applied to the framework in order to tailor the approach to the individual clients. Similarly, evidence-based intervention approaches, across the continuum of care, that are easily implemented, culturally responsive and ecologically valid (Finch et al., 2016; Lê et al., 2022; Muelenbroek et al., 2019; Togher et al., 2023) are outlined in the context of this framework, where skills, environment, demands and identity are accounted for and emphasized. Case examples are used to highlight the application of assessment and treatment decisions to this SoCIAL framework. This poster will provide a structure for supporting clinical implementation of individualized, literature supported assessments and interventions while also moving translational research forward.

Conclusion: There is a growing literature base that supports a focus on social communication in context, however, there a gap remains between the literature and clinical application, that this framework hopes to begin to address. The SoCIAL framework highlights the intersecting variables (contextual, social, personal and environmental) that can be considered during the assessment and intervention process as person centered, culturally responsive care is planned.

Purpose: The authors sought to identify the perceived met, unmet, and undermet needs of individuals living with traumatic brain injuries and their family members within a Midwestern state as part of a required state needs assessment.

Method: Participants were recruited at the annual state support group summit and by reaching out to virtual support groups. Participants completed the OSU-TBI form, a demographic questionnaire, the SPRS-2, and then a qualitative interview. Family members were included in the data collection process and participated in the interviews as necessary to support communication of the individuals with TBI. Demographic and SPRS-2 score data were reported providing descriptive information on changes in participation and relationships post injury. This data is augmented by qualitative responses on the SPRS-2 describing these changes. Interview data was analyzed using a grounded theory approach to code key statements, identify clusters of meaning and highlight the salient experiences of the individuals in various contexts and situations. Each interview was coded separately by at least two members of the research team (authors) and all authors have expertise and training in qualitative analysis.

Results: 34 individuals with TBI (15 female and 19 male) between the ages of 30 and 84 years old participated in the study. Their injuries ranged from mild to severe (8 mild, 10 moderate, 12 severe, and 4 non-traumatic etiology). The time post injury onset of the participants ranged from 4 months to 62 years (M = 11.24, SD = 12.67). The injury onset ages of the participants ranged from 16 to 60 years old (M = 44, SD = 12.96). 91.2% of the participants identified their race/ethnicity as white, while 8.8% identified as Black or African American. In terms of educational background, 4 participants finished high school, 3 completed some college, 10 had earned an associate’s degree, 12 attained a bachelor’s degree, 3 completed a master’s degree at the graduate level, and 2 had obtained a doctorate degree. The average length of interviews was approximately 71 minutes (range = 44 - 109 minutes; standard deviation = 22.76). Data analysis and coding of qualitative interviews is currently underway and will be available for report by March 2025.

Conclusion: This work highlights the importance of efforts to understand the lived experiences of individuals with TBI and has implications for healthcare providers, family members, and others who may interact with those who have experienced a TBI. The public health burden of TBI is great, thus the need for this state based assessment, and this study provides valuable insight into the services and supports needed for individuals with TBI. Future endeavors should involve the creation of resources and programming that meet the needs of these individuals and their families.

Background: Traumatic brain injury (TBI) is a leading cause of cognitive and communication impairments in older adults, affecting areas such as memory, attention, and executive function. These deficits often manifest in conversational discourse, where individuals may struggle with verbal fluency and maintaining coherence. While discourse analysis in aging adults, including those with neurodegenerative disease, is well-documented, less is known about how aging with TBI further influences discourse. Effective discourse is critical for maintaining social connections and quality of life in older adults, making it important to understand how TBI affects conversational abilities in this population. This study analyzed conversational discourse in older adults with and without TBI, focusing on differences in discourse variables: coherence, verbal fluency, mean-length utterance (MLU), and length to response time.

Methods: Participants included 52 older adults aged 65 and above (TBI=25, no TBI=27) recruited from the community. The TBI group had a history of mild-to-moderate TBI, confirmed through medical documentation. All participants were English-speaking and had no more than mild cognitive impairments, as assessed by standardized cognitive screening tools. Conversational discourse was elicited through medical conversational discourse, where participants engaged in back-and-forth discussions related to a healthcare conversation (fall prevention education). These conversations were recorded, transcribed, divided into c-units, and analyzed with Systematic Analysis of Language Transcripts (SALT). Coherence was assessed using topic maintenance, relevance, and logical flow measures. In contrast, mean length utterance and verbal fluency were measured by speech rate, pauses, word retrieval difficulty, and the number of fillers (e.g., "um," "uh"). Group differences were examined using ANOVA.

Results: There were no differences in verbal fluency (F(1, 50) = 3.69, p=.076) or length to response time (F(1, 50) = 8.56, p=.082) between older adults with and without TBI. There were significant differences in both coherence (F(1, 50) = 15.45, p=.002) and mean length utterance (F(1, 50) = 13.43, p=.004) were found between older adults with and without TBI. The TBI group demonstrated reduced coherence, with more frequent topic shifts, irrelevant statements, and difficulties maintaining a logical flow in conversation, which may also account for the longer utterance lengths. In contrast, participants without TBI demonstrated more coherence in discourse with shorter MLU than those with TBI.

Discussion: The findings suggest that older adults with TBI demonstrate increased differences in coherence and MLU compared to older adults without TBI. These impairments may result from differences in cognitive function, such as reduced executive functioning that older adults with TBI may experience as more pronounced than those aging without TBI. As such, additional support may be needed for older adults aging with TBI to maintain coherence in conversational discourse. Future research should explore the impact of these conversational implications on social participation and quality of life.

Background: Falls are the leading cause of death and nonfatal injuries in adults 65 and older in the U.S. and a primary cause of traumatic brain injury (TBI). TBI often results in lasting cognitive deficits, such as memory, attention, and executive function issues. As TBI requires lifelong management, fall prevention must be adaptable to address the needs of those aging with TBI. Self-management strategies like mental contrasting with implementation intentions (MCII) have shown promise in promoting behavior change. MCII includes five manualized steps, including 1) goal identification, 2) goal relevancy, 3) barriers to goal, 4) strategies to overcome a barrier, and 5) creating a plan to complete the goal. While MCII is client-centered, its adaptability for fall prevention in clinical settings, particularly for older adults with TBI, remains underexplored. This study assessed the adaptations required for MCII in older adults with and without TBI, delivered by student clinicians.

Methods: Older adults aged 65 and above, with or without TBI, were recruited from the community. Participants had to be English-speaking and have no more than mild cognitive or language impairments. Those with TBI provided medical documentation. Ten first-year speech-language pathology Master’s students and five senior undergraduates in speech-language pathology were trained to deliver the manualized MCII intervention. A mixed-method experimental design was employed, with data collected at two points: 1) during the MCII intervention and 2) at least three weeks after the intervention in a semi-structured interview. Both in-person and virtual formats were used. Outcome measures included treatment adaptations across the five MCII manualized steps and qualitative interview data from clinicians and participants.

Results: Forty-one older adults participated (TBI=19, no TBI=22). Participants with TBI required more intervention adaptations (F(1)=6.8, p=.012). Adaptions primarily occurred in the later stages of MCII (identifying barriers and strategies, and creating a plan). Adaptions were fidelity consistent with the MCII protocol and included increased repetition, examples, and cognitive support for planning and organizing. Clinicians rated MCII equally appropriate for people with and without TBI (F(1)=.908, p=.345). Still, they noted the need for flexibility in delivering MCII to participants with TBI for participants to be successful. Participants echoed this overall reflection of MCII as a strategy, with people with TBI finding the strategy helpful but requiring additional support and guidance to complete MCII.

Discussion: MCII shows potential as an adaptable tool for fall prevention in older adults, including those with TBI. While participants with TBI required more individualized support and modifications, both groups used the strategy to learn and execute fall prevention strategies. These results underscore the importance of tailoring interventions like MCII for older adults with TBI. Further research is needed to assess the broader applicability of these adaptations across diverse populations and clinical settings.

Job loss and insecurity don’t just impact financial stability—they strike at the core of health equity. For many individuals with an acquired brain injury (ABI), returning to work is the ultimate goal in recovery. Yet, the path to returning to work is especially challenging, with systemic and attitudinal barriers at every corner. From a lack of understanding from employers and changes in relationships with colleagues to difficulties managing symptoms and mental health challenges, individuals with ABI are often left to traverse this path alone without support. The Ontario Brain Injury Association forged an alternative to the current landscape by developing and evaluating an innovative, first-of-its-kind return-to-work program offered at no cost to employers and individuals with ABI.

Program Overview: The program offers an online training program and access to interdisciplinary support for individuals with ABI and their employers as they navigate the complex process of re-entering the workforce. By supporting individuals with ABI, we aim to improve their overall quality of life by increasing awareness of mental health challenges and building capacity for symptom management. In partnership with their employer, we strive to shatter barriers to create more inclusive workplaces for individuals with invisible disabilities. Our pre-program results underscore the importance of this comprehensive support.

Program Evaluation: The evaluation involved 32 participants, 75% women, predominantly between the ages of 25 to 64. Most participants (97%) had some level of post-secondary education, and most (72%) reported earning more than $50,000 annually. Validated measures to assess overall well-being before their involvement with the program included the Quality of Life after Brain Injury-Overall Scale (M=33.82, SD=18.85) and the Acceptance and Action Questionnaire-Acquired Brain Injury (M=30.06, SD=9.19). Scores from these measures demonstrated that participants reported poor quality of life and low levels of acceptance of their injury pre-program. Participants also completed the Depression, Anxiety and Stress Scale, which indicated participants experience severe depression (M=26.5, SD=11.71), extremely severe anxiety (M=23.25, SD=8.79), and severe stress (M=30.75, SD=9.80). After six months, participants were reassessed and results were compared across three groups. All completed the online training, but the groups differed in access to the interdisciplinary team and employer involvement: Group One completed only the training, Group Two received interdisciplinary services without employer involvement, and Group Three received both interdisciplinary services and employer support.
This session will present an overview of the program, explore client outcomes and the preliminary results on the program’s effectiveness. Finally, we will provide the audience with our lessons learned. Attendees will leave the presentation with the foundational knowledge needed to implement the program worldwide, improving return-to-work outcomes for individuals with ABI.

Introduction: Several studies have suggested that higher levels of depression are associated with lower scores on neuropsychological tests. However, consistent with the strong association between right hemisphere damage (RHD) and anosognosia, an under-endorsement of depressive symptoms in individuals with RHD from stroke has also been reported. This suggests that an underreporting of depression may occur in individuals with signs of RHD on neuropsychological testing. The current study examined whether depression ratings were correlated with cognitive test scores in individuals undergoing neuropsychological testing for traumatic brain injury (TBI).

Methods: Individuals (age range 20 to 38 years) with complicated mild, moderate, or severe TBI and demonstrated intracranial pathology on CT scan (CT+) were compared to a second age- and education-matched sample consisting of mild TBI with negative CT scans (CT-). Exclusion criteria were for pre-morbid psychiatric illness and/or suggestion of malingering on a formal test of effort. The severity of depression was measured with the Beck Depression Inventory-II (BDI-II), with higher scores reflecting higher levels of depression. Cognitive variables examined were tests of processing speed and generative output: Coding from the Wechsler Adult Intelligence Scale-IV (WAIS-IV), phonemic and semantic word generation, and figural fluency [output (FF output) and perseverative error (FF error) scores], using an adaptation of the Ruff Figural Fluency Test.

Results: There were no significant differences in the test scores of the CT+ (n = 16) and CT- (n = 16) groups. In the combined sample (N = 32), the only significant (p < .05) correlation found between depression ratings on the BDI-II and cognitive variables was for FF output (r = .43, p = .01), with a positive correlation indicating a relationship of lower non-verbal fluency scores to lower levels of depression. Similarly, in CT+ (n = 16), there was a significant correlation of FF output with depression (r = .75, p = .0009). In CT- (n = 16), this correlation did not emerge. Glasgow Coma Scale (GCS) scores in CT+ were correlated with scores on Coding (r = .48. p =.06), FF output (r = .44, p = .09), FF errors (r = -.50, p = .05), and BDI-II scores (r = .48, p = .06).

Conclusion: This study suggests that lower reporting of depressive symptoms in examinees with intracranial injury is correlated with lower GCS scores and signs of RHD on neuropsychological testing, consistent with studies showing less awareness of depression, or “nondysphoric depression” in individuals who have had right hemisphere strokes. This result is also consistent with the findings of an increased incidence of alexithymia – an impairment of emotional awareness – following TBI. Future research will increase the sample size and consider variables such as outward affect, activity level, and treatment medications in data interpretation.

Background: Traumatic brain injury (TBI) is a significant public health concern. Consumer product-related brain injury (CP-TBI) is common and more frequent in older adults, resulting in poor outcomes. Understanding CP-TBI trends and risk factors in older adults may inform and contribute to implementing effective prevention strategies reducing incidence, morbidity, and mortality.

Methods: Serial cross-sectional data extracted from the National Electronic Injury Surveillance System (NEISS) for 2001-2020 were analyzed. The incidence rate of CP-TBI (TBI-IR) was the primary outcome, calculated as a number of cases per 100,000 population using statistical weights and standardization using the U.S. Census population corresponding to calendar year by sex and age groups. Joinpoint regression was used to examine temporal trends for TBI-IR changes in magnitude and direction illustrated by annual percent changes (APC) and average annual percent changes (AAPC).

Results: Approximately 54.1 million older adults aged ≥ 65 years arrived at EDs for CP-related trauma care (CP-ED) in 20 years, accounting for 20.0% of all CP-ED visits. Of these, 8.6 million patients sought TBI care, accounting for 15.9% of all CP-ED, with an average of 429 thousand CP-TBI cases and an increased TBI-IR of 5.8% annually. Most CP-TBI patients were women (57.5% vs. 42.5% men) with higher TBI-IR in females than males, strikingly after 2007, highest in the group of ≥ 85-year-old males and females.

Joinpoint regression models revealed overall TBI-IR trends in older adults segmented into three periods by two joinpoints in 2007 and 2010, with an AAPC of 5.8% and higher in females (6.4%) than males (5.8%). The highest AAPC change was in the 75-84-year-old males (9.5%). TBI-IR increased significantly in females in all three segments, with an APC of 7.2% in 2001-2007, the highest APC of 16.9% in 2007-2010, and a slower increase of 2.9% APC in 2010-2020. TBI-IR increased slower in males than females and had two segments, with APC of 7.5 % in 2001-2011 and 2.8% in 2011-2020. Most TBI incidents occurred at home (59.6%), followed by public property (15.7%), places of recreation/sports (13.7%), and others (11.0%). Alcohol and drugs involved at least 5.3% (higher in males) and 3.7% (no sex difference) of total CP-TBI, respectively. The most common causes of CP-TBI involved contacting floors/flooring materials, stairs/steps, bed/bedframes, bathtubs/showers, chairs, and salient activities in females and males. Football, bicycling and basketball were common causes of CP-TBI in males. Deaths involving CP-TBI were estimated at 0.13% of all CP-ED in older adults.

Conclusion: TBI-IR in older adults increased from 2001, strikingly in 2007-2010, especially in females. Effective prevention strategies should be utilized to tailor to older adults while informing families and caregivers. As part of a comprehensive safety and risk mitigation program, especially involving daily activities and bright light at home.

Objective: Women survivors of intimate partner violence (IPV) often experience traumatic brain injury (TBI) due to IPV, report neurobehavioral symptoms, and experience posttraumatic stress disorder (PTSD) and chronic pain. The cooccurrence of neurobehavioral symptoms, PTSD, and chronic pain has previously been defined as the polytrauma clinical triad among Veterans, but the triad has not been studied among women survivors of IPV. This study examined the rates of neurobehavioral symptoms, PTSD, chronic pain, condition dyads, and the polytrauma clinical triad among a sample of women survivors with no lifetime history of TBIs and women with IPV-related TBIs.

Methods: Cisgender women were recruited using Prolific, an online recruitment platform (N=198; M=39.6 years-old, SD=11.9; 83.3% White, 82.9% non-Hispanic; 59.1% college-educated). All participants reported a history of physical or sexual IPV, with 53.0% (n=105) reporting at least one prior IPV-related TBI. Among women reporting TBIs, most reported mild TBIs (90.5%), with their most recent injury occurring more than one year ago (92.4%). All participants completed the Neurobehavioral Symptom Inventory (NSI) and PTSD Checklist for DSM-5 (PCL-5), and additionally, self-reported their pain frequency and duration (i.e., pain most days for ≥ 3 months qualified as chronic pain).

Results: Women with IPV-related TBI were more likely to report chronic pain (43.8%) than women survivors of IPV without a lifetime history of TBI (29.0%) (p=.045, OR [95% Confidence Interval]=1.87 [1.01, 3.43]). However, rates of neurobehavioral symptoms and PTSD did not differ across groups. For condition dyads, women with IPV-related TBI were more likely to meet criteria for dyads that included chronic pain: chronic pain with concurrent neurobehavioral symptoms (p=.030, OR=2.01 [1.07, 3.79]) and chronic pain with concurrent PTSD (p=.009, OR=3.84 [1.41, 10.46]). Similarly, women with IPV-related TBI were more likely to meet criteria for the polytrauma clinical triad (19.0%) than women survivors without TBI (6.5%)(p=.009, OR=3.84 [1.41, 10.46]). All analyses controlled for age and education, but when additionally controlling for physical and sexual IPV severity, all group differences became nonsignificant.

Conclusions: The current findings suggest that, compared to women survivors of IPV without lifetime history of TBI, women survivors with IPV-related TBI are more likely to meet criteria for the polytrauma clinical triad regardless of age and education. IPV severity explained the relationship between TBI history and mental and behavioral health symptoms, suggesting that IPV severity is closely linked to both risk of TBI and elevated symptomatology in this population. Results also suggest that chronic pain may be the largest contributor to the polytrauma clinical triad among this population, highlighting the importance of incorporating pain management into interventions for women survivors of IPV.

Background: Neck pain is a frequent symptom following concussion, often resulting in prolonged recovery and reduced quality of life. Despite its prevalence, there is no consensus on an effective therapeutic protocol. Management typically includes rest, physical therapy, NSAIDs, and more invasive interventions like facet joint and medial branch blocks. Identifying effective and standardized treatment protocol is essential for enhancing patient outcomes. This systematic review evaluates the effectiveness of various treatments for post-concussion neck pain to inform clinical practice.

Methods: We conducted a systematic search of PubMed, SPORTDiscus, Embase, and CENTRAL up to June 2024, using keywords such as "neck pain," "concussion," and “treatment" and their synonyms. Studies were included if neck pain was the main post-concussion symptom and physical examination and radiographic imaging were used to assess improvements. The single-patient case reports were excluded. Bias was assessed using Cochrane Risk of Bias 2 Tool.

Results: Database searches yielded 287 eligible studies, of which 123 were selected for full-text review. After applying the inclusion criteria, 23 studies of the highest significance were included in the final analysis. The main interventions evaluated were physiotherapy (n = 11, 47.8%), facet joint/medial branch blocks (n = 7, 30.4%), and chiropractic care (n = 4, 17.4%). One study (4.3%) investigated the use of NSAIDs. Moderate-quality evidence suggested that a combination of physiotherapy and at-home neck exercises is most effective for managing neck pain and increasing range of motion in patients 1-2 months following concussion. Low-quality evidence indicated that combining chiropractic spinal manipulations with physiotherapy may be more effective at reducing neck pain than physiotherapy alone. Limited evidence was found for the continuous use of NSAIDs. For patients with chronic neck pain (≥ 3 months post-concussion), facet joint and/or medial branch corticosteroids injections were recommended following physical examination. Patients receiving these injections experienced a significant reduction in pain relief, lasting for 14-16 weeks.

Conclusion: Clinicians should consider incorporating physiotherapy and at-home neck exercises into their treatment plans for patients with acute neck pain post-concussion. For chronic cases, facet joint and/or medial branch injections may be considered. Monitoring patients for treatment responses is crucial to optimize outcomes.

Objective: The Vestibular Ocular Motor Screen (VOMS) and the Sport Concussion Assessment Tool 6 (SCAT6) are commonly used point-of-care concussion assessments that typically are administered immediately or soon after sport participation/exercise. Point-of-care concussion assessments ideally should not be affected by physical exertion to remain valid. This study assessed the effects of practice participation or high-intensity exercise on the mVOMS (modified VOMS) and SCAT6 in non-concussed high school athletes.

Methods: Adolescent athletes (n=23, 39% male, 15.5 ± 1.0 years) completed the SCAT6 and the mVOMS before exercise, immediately after exercise, and after a 20-minute rest. Exercise was a standard sport practice. Rating of Perceived Exertion (RPE) and heart rate (HR) were measured at each time point to confirm the exercise intensity. The post-practice assessment was conducted only if the RPE was ≥ 17 or HR was ≥ 80% of the age-predicted maximum. Participants who did not meet these criteria completed a high-intensity 300-meter shuttle run before the second assessment.

Results: Timed Tandem Gait (TTG) (p=0.005) and Dual Task Tandem Gait (DTTG) (p=0.045) improved significantly from pre- to immediately post-exercise as well as from pre- to 20-minutes post-exercise (TTG [p=0.002] and DTTG [p=0.006]). There were no other differences in SCAT6 or mVOMS scores among the three time points.

Conclusions: SCAT6 and mVOMS performance was not adversely affected by high levels of physical exertion. TTG and DTTG performance improved after exercise, likely due to the learning effect. Further research should be conducted on other populations to increase the generalizability of our findings. Clinicians can be confident that physical exertion does not negatively impact performance in these widely used sideline concussion assessment tests in non-concussed adolescent athletes.

Objective: Current guidelines for sport-related concussion (SRC) management rely on self-reported symptoms and clinical examinations, which can be subjective and occasionally prone to error. Brain-Derived Neurotrophic Factor (BDNF), a neurotrophin that promotes neuronal healing, may be informative for SRC management. Aerobic exercise is recommended for SRC recovery, and BDNF expression increases with the volume of aerobic exercise. This pilot study measured salivary BDNF in adolescent athletes prescribed aerobic exercise throughout a two-week intervention.

Methods: Athletes with SRC (n=32, 15.6 ± 1.4 y/o, 66% male, 6.2 ± 2.2 days from injury) and controls (n=28, 16.0 ± 1.6 y/o, 68% male) provided saliva samples and completed standard clinical exams at initial visit, 7 and 14 days later. Participants were randomly assigned to either high (5 days/week, 30 min) or low (3 days/week, 20 min) volumes of aerobic exercise. An optimized methodology was used to process saliva samples, and BDNF levels were measured in triplicates using an Enzyme-Linked Immunosorbent Assay (ELISA, R&D System).

Results: Concussed females had higher initial salivary BDNF than controls (67.3 pg/mL vs. 42.4 pg/mL, p=0.002), which persisted throughout the intervention. Males showed no differences. The change in BDNF between the initial and final visits was not associated with exercise volume. Salivary BDNF expression in concussed adolescents was not associated with relevant clinical findings. There was a near significant association after Bonferroni correction (p=0.025) of change in BDNF and time to first visit in females (p=0.037). Concussed females presented later to the initial encounter than males (7.7 ± 4.2 vs. 4.9 ± 2.6 days, p=0.044).

Conclusion: Our data show that sex plays a significant role in salivary BDNF expression. This should inform future research on the physiology of concussion. Our data also suggest that the female BDNF expression may depend on the time since injury. Future studies should attempt to collect salivary BDNF closer to the point of injury. Our data did not show a relation of exercise volume to BDNF, likely due to the brief length of the intervention. Our novel analytical methods helped to ensure reliable BDNF measurement and should be emulated in future studies. Further investigation of the association between sex, recovery time, exercise, and BDNF modulation with a larger sample size is warranted and could have practical implications for clinicians treating concussed adolescents.

Introduction: frequently observed after Acquired Brain Injury (ABI). Virtual reality (VR) can potentially overcome challenges associated with conventional rehabilitation by providing personalized, feedback-enhanced, and goal-oriented exercises. However, the execution of daily tasks requires motor and cognitive skills which often differ from typical virtual settings. We have developed a non-immersive VR system that incorporates real photographs of living spaces, allowing including interactive elements within various game scenarios which require participants to identify or position items using motor and cognitive functions. This study aimed to evaluate usability, presence, flow, competence, utility, and pleasant and unpleasant sensations of this VR system in ABI survivors.

Methods: 30 individuals with ABI (15 with traumatic brain injury and 15 with stroke) participated in this study. Participants (43.4% were female) had an average age of 55.8 years (SD=15.5) and a mean time post-injury of 30.1 months (SD=59.3). Each participant engaged with three different exercises, each lasting 4 minutes, with a 2-minute rest between exercises. Following the interaction, participants completed the System Usability Scale, the Flow State Scale 2, the Slater-Usoh-Steed Questionnaire, the Game Experience Questionnaire, and the Intrinsic Motivation Inventory.

Results: Participants found the system to be highly usable, rating it 81.4±10.4 over 100. They felt it provided clear goals (7.8±0.9 over 9) and unambiguous feedback (7.7±1.1 over 9). Additionally, participants experienced a strong sense of presence (4.9±1.9 over 7). In terms of flow, participants reported experiencing this state (2.7±0.7 over 4), with action-awareness merging (6.3±1.4 over 9), time transformation (4.3±2.5 over 9), focused concentration on the task (8.0±1.1 out of 9), and a loss of self-consciousness (7.5±2.1 over 9). Regarding competence, ability, and control, they perceived themselves as competent (2.8±0.7 over 4 and 4.8±0.8 over 7), sensed a balanced challenge-skill ratio (7.2±1.2 over 9), and felt in control (7.4±1.5 over 9). Participants also reported positive sensations such as interest and enjoyment (5.2±0.7 over 7), autotelic experiences (7.0±1.7 over 9), immersion (3.1±0.9 over 4), and positive affect (3.2±0.8 over 4). In contrast, they reported low levels of pressure (3.1±1.0 over 7), tension (0.2±0.3 over 4), negative affect (0.3±0.5 over 4), and challenge (1.0±0.8 over 4). Lastly, they considered the system useful (5.1±1.1 over 7).

Conclusions: The gamified, VR-based exercises in realistic environments were found to be both usable and effective in promoting a strong sense of presence and flow. Participants felt capable, in control, and experienced positive sensations without negative emotions. They also saw the system as a valuable tool for rehabilitation.

ACKNOWLEDGEMENTS: This work was supported by Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15), Ministerio de Ciencia e Innovación (PID2022-141498OA-I00), and Fundació la Marató de la TV3 (60/2023).

Objectives: To determine if a protocolized photo diary intervention can be beneficial to patients with memory impairment after msTBI.

Background: Memory impairment is a central feature of patients who suffer a msTBI. Even after clearing Post Traumatic Amnesia [PTA] by clinical metrics, many patients demonstrate persistent impairments in short term memory, which impacts their ability to recall basic daily events and participate effectively in the rehabilitation process. Specific to patients with ongoing severe episodic memory impairments, discharge back to their families and community can be complicated by the need for 24/7 care and supervision. Cognitive therapy for patients with memory deficits following msTBI typically revolves around low tech external memory supports such as a journal and written reminders to try and enhance episodic recall. In our review of the literature there has been little in the way of clinical studies that look at the use of high tech photo journaling to support this population and assist patients in laying down basic day-to-day memories.

Methods: This is a retrospective chart review of ten patients with ongoing severe short term memory deficits after emergence from PTA following msTBI. All patients reviewed were inpatients admitted to a comprehensive specialized brain injury rehabilitation unit and were being treated by a single Speech Language Pathologist [SLP]. Patients were given a touch screen tablet device with a commercially available photo diary application. Use of the device was guided by daily interaction with the study’s SLP. Patients, families, and staff were instructed to take photos with the device of the patient participating in relevant therapy activities during their day. These photos were then reviewed in the SLP therapy sessions. The primary outcome was documented improvements in day-to-day recall of events as reported by patient, family and staff members. Secondary outcome measures included length of stay in rehabilitation, functional scores at discharge [Care Tool and Disability Rating Scale], and disposition at discharge from the rehabilitation unit.

Results: All patients had documented improvement in day-to-day memory and recall at the end of inpatient treatment. Some of the patients exhibited reduced confabulations when reviewing photo diaries and some had better self-awareness of events that occurred in their day. In general, this intervention was well accepted by patients and their families.

Conclusions: The photo-diary treatment intervention was well accepted by both patients and families and has potential value in treating the ongoing memory deficits common to patients with msTBI on an inpatient rehabilitation unit. A proposed protocolized treatment intervention will be presented for discussion. Further study looking prospectively at this intervention is warranted.

Subconcussive head impacts during contact sports are challenging to identify and their consequences on athletes’ health remain elusive. Impaired autonomic nervous system responses involving cardiac autonomic dysfunction have been reported following mild traumatic brain injury but this potential brain-heart interaction remains underexplored in contact sports. The objective of this study was to monitor the real time effects of head impact exposure on athletes’ cardiovascular function during an entire Varsity Canadian football season. Heart rate recovery (HRR) segments (n=225) were extracted from 11 skill players (median [IQR] age: 23 [2] years; body mass index: 26 [1] kg/m²) equipped with two wearable sensors (Catapult vest and Athlete Intelligence instrumented mouthguard) recording accelerations, heart rate, velocity, estimated metabolic energy expenditure, as well as fast head acceleration events (HAE), so-called impacts. The heart signal derivative was used to detect HRR segments which were then matched with the number and intensity of HAE previously sustained during the game by each athlete. Following a single HAE above 40g, the median HRR (ΔHR/Δt=0.461 bpm/s, n=23 segments) decreased of 19% (p=0.005) compared to segments prior to the event (ΔHR/Δt=0.569 bpm/s, n=182 segments). This reduction was also observed with HAE as low as 20g (0.474 bpm/s, n=42 segments; 30% reduction; p= 4.30e-08). These events impaired HRR and were neither correlated with metabolic energy expenditure (R²=0.009, p=0.541) nor with peak running velocity reached before HAE (R²=4e-04, p=0.896). This demonstrates a possible direct causal relationship between HAE starting at 20g and disturbed cardiac response potentially through autonomous nervous system dysregulation. Given the repetitive nature of subconcussive hits beyond this potential ≥ 20g head injury susceptibility range, especially in professional contact sport athletes, there is an urgent need to investigate whether or how altered heart rate kinetics could influence susceptibility and severity of head injury in contact sports.

Background: Post-concussion syndrome is a challenging condition to manage for even the most experienced chronic pain experts. Patients’ presentations are heterogeneous with symptoms spanning physical, cognitive and emotional domains. Regrettably, the symptoms reported have been shown to be non-specific, making it difficult for health professionals to prescribe effective rehabilitation. The aim of the present study was to examine the effectiveness of an individualized rehabilitation program based on subgroup determination following a standardized clinical exam in adults with persistent post-concussion symptoms.

Methods: A total of 16 adult participants (mean age [SD], 38.3 [12.5] years] with persistent post-concussion symptoms participated in a six-week rehabilitation program. Participants were recruited from various external community concussion clinics around the greater Toronto area, Canada. Participants underwent a comprehensive standardized clinical exam to subgroup the ostensible symptom generators. Individualized rehabilitation was then prescribed based on their subgroupings. The primary outcome measure was the Rivermead Post concussion Questionnaire (RPQ). Secondary outcome measures included the Neck Disability Index (NDI), the Patient Health Questionnaire-9 (PHQ-9), and exercise tolerance as assessed via the Buffalo Concussion Treadmill Test (BCTT).

Results: Following six weeks of individualized rehabilitation, participants on average experienced a significant and clinically meaningful change with respect to the RPQ-3 and RPQ-13 (mean change, SD [95%CI] || RPQ-3: 4.6 + 2.4, [3.5-5.6], p<0.001; RPQ-13: 13.3 + 8.4, [9.5-16.9], p<0.001). Additionally, we observed a significant change in all secondary outcome measures including a reduction in PHQ-9 (mean change, SD [95%CI], 4.4 + 6, [1.7-7], p<0.01), NDI (mean change, SD [95%CI], 7.8 + 6.8, [4.7-10.7], p<0.001) and exercise tolerance (mean change heart rate threshold, SD [95%CI], 27.8 + 24.1 [10.6-38.4] beats per minute, p<0.001).

Conclusion: The standardized exam was feasible and useful in assisting the clinician in prescribing an effective individualized rehabilitation program for adults with persistent post-concussion symptoms. Subgrouping persistent post concussion symptoms based on a standardized exam may be key to successful management in this population.

Every year, 200 000 children experience a concussion in Canada (Goulet & Beno, 2023). Concussions are the most prevalent type of traumatic brain injuries (TBI) and disrupt physical, cognitive, family, social and behavioral functioning (Beauchamp & Anderson, 2013). Among the former, executive functions (EF) can be vulnerable to disruption. EF include abilities such as inhibition, planning and flexibility which are especially important in childhood because they form the basis of higher order abilities necessary for social interactions and academic achievement. While many studies report on EF after pediatric TBI, few have focused on the integrity of these abilities after milder injuries or in preschool children, despite their importance for school readiness. The objective of this study was to document EF in the long-term after early childhood concussion. Children (n= 169, mean age= 5.66; SD= 1.00) with either concussion (n= 66), orthopedic injury (OI, n= 42) or typical development (TDC, n= 61) aged 18 months to 5 years were recruited to participate in a longitudinal study. At 30 months post-injury, participants’ parents completed the Behavior Rating Inventory of Executive Function (BRIEF) measuring inhibition, shifting, emotional control, working memory, planning/organization, inhibitory self-control, flexibility and emergent metacognition. Participants were divided into a younger (4 to 5 years at the time of testing) and older (5 to 7.5 years) group. ANOVA showed no differences between the concussion (n= 47), OI (n= 25), and TDC (n= 44) for older children, F(2,113)= 0.667, p= 0.515 in the standardized global executive composite score. However, in the 4-5 years group, the global executive composite score differed significantly between groups, F(2,50)= 4.875, p= 0.012. Children with concussion (n= 19) (p= 0.23) had poorer EF than TDC (n= 17) (mean difference= 9.437; SD= 3.404), but not from OI (n= 17) (p= 1.000); however, OI also had poorer EF than TDC (p= 0.032) (mean difference= 9.294; SD= 3.498). Differences were also observed for inhibition F(2,50)= 4.809, p= 0.012 between the TBI and TDC p= 0.012 (mean difference= 10.034; SD= 3.317), planning/organization F(2,50)= 4.541, p= 0.015 between the OI and TDC, p= 0.025 (mean difference= 10.647; SD= 3.881), inhibitory/self-control F(2,50)= 4.658, p= 0.14 between the concussion and TDC p= 0.018 (mean difference= 10.158; SD= 3.538) and emergent metacognition F(2,50)= 3.859, p= 0.028 between concussion and TDC, p= 0.044 (mean difference= 9.269; SD= 3.662). The findings suggest that children injured younger have more long-term effect on EF than those injured older. Possible interpretations for age differences could be related to neuroplasticity effects or to the exposure of school-age children to EF training as opposed to those not yet in formal school settings. These results underscore the importance of screening for EF and monitoring progression throughout the early years.

Objectives: The Glasgow Coma Scale (GCS) is the gold standard in assessing severity for pediatric traumatic brain injury (pTBI) in medicine and research, yet GCS inconsistently tracks with long-term outcomes and is not frequently used outside of the medical system. A reliance on GCS-determined severity as the primary severity indicator, artificially reduces heterogeneity in research and limits the understanding of long-term outcomes following pTBI. The primary objective of this study was to compare GCS-rated severity to caregiver-rated severity. Researchers assessed levels of agreement and explored factors that explained differences in ratings. Researchers also assessed what factors determine whether a GCS score is provided in the medical record.

Methods: Researchers examined severity for 107 youth with TBI at a large US, midwestern children’s hospital. Caregiver-reported severity, demographic and medical care information was collected via electronic survey. GCS-rated severity was collected via medical-chart review.

Results: There was a moderate agreement (k=0.50) between caregiver-rated severity and GCS-rated severity. The strength of agreement fluctuated at different levels of severity (mild/concussion k= 0.60, moderate k=0.1, severe k=0.64). Severity ratings did not match in 32% of cases. Caregiver severity ratings were more severe than GCS-rated severity in 62% (n=5) of cases. No medical or demographic variables explained discrepancies between caregiver-rated severity and GCS-rated severity at levels of statistical significance. Just over one-third (38%) of total participants had a documented GCS score in their medical record. Binomial regression modeling found that only highest acuity of care significantly predicted whether a GCS score was provided. Participants seen in the Emergency Department were more likely to receive a GCS rating, compared to those seen in urgent care or pediatrician/clinic offices.

Conclusion: The results suggest that caregivers may be reliable evaluators of the severity of their child’s TBI, particularly for those with mild or severe injuries. Allowing parent-reported severity as a measure of injury – and not requiring GCS-ratings- has the potential to increase inclusivity in research participation, such that participation in research is not limited to children who seek medical care, especially from an Emergency Department. These findings invite further study into the nuance of the differences between caregiver-rated severity and GCS-rated severity. More research is needed to determine if caregiver-rated severity tracks consistently with long-term outcomes or if caregivers base severity ratings on other factors outside of the initial acute injury event.

Ongoing engagement in cognitive exercise is a key pillar of brain health and can result in benefits to individuals with and without acquired brain injuries (ABI). A growing body of evidence supports that exercise-facilitated neuroplasticity can enhance brain health, function, and quality of life. Four studies led by this presenter will be summarized: 1) two studies that examined cognitive benefits of cognitive exercise to adults with chronic moderate-to-severe (m-s) cognitive impairments post-ABI; 2) one study that examined motivational challenges to cognitive exercise engagement by adults with m-s cognitive impairments post-ABI, and 3) one study that examined cortical stimulation associated with various cognitive exercises as measured by electroencephalography (EEG). Regarding the two studies addressing cognitive benefits of cognitive exercise: 1) results of a 5-month, 5-day/week individual computerized cognitive exercise comparison group pilot study (n = 14) revealed that performance by the exercise group versus the control group on auditory memory and verbal fluency standardized assessments significantly improved (M=8.43, t(10)=3.40, p=0.0068; M=15.40, t(10)=2.51, p=0.0310 respectively), with the majority of exercise group participants subjectively reporting that program engagement positively impacted their cognitive abilities and everyday function; and 2) results of a 12-month weekly group cognitive exercise pilot study (n = 10) revealed that participants post-group Brief Test of Adult Cognition by Telephone Composite z-scores were significantly better than their pre-group composite z-scores (M = -0.7240, t(9) = 4.0637, p = 0.0028). Regarding the study addressing motivation to engage in cognitive exercise, results of a mixed methods study (n = 34) revealed that participants perceptions of motivational facilitators included ‘receipt of positive reinforcement for exercise activity’, ‘possession of needed information to engage in exercise’, and ‘possession of exercise-related goals’ and that their perceptions of motivational barriers included ‘absence of exercise-related goals’ and ‘absence of consistent structure conductive to exercise’. Regarding the study addressing selection of cognitive exercises based on cortical stimulation associated with them as measured by EEG (n = 25), in left dorsolateral prefrontal cortex (LDLPFC) coherence comparisons between ‘most cognitively challenging’ and ‘least cognitively challenging’ activity conditions, coherence was significantly higher for Sudoku, the activity rated ‘most cognitively challenging’ by most participants, than for ‘least cognitively challenging’ activity conditions at F3-AF3 in high beta (p = 0.0215); at F3-Fz in beta (p = 0.0327), theta (p = 0.0012), delta (p = 0.0266), and high delta (p = 0.0171); and at F3-FC1 in theta (p = 0.0105), delta (p = 0.0171); and high delta (p = 0.0171). In comparisons between Sudoku and an ‘at rest’ condition, LDLPFC coherence was significantly higher for Sudoku at F3-FC1 in theta (p = 0.0479), delta (p = 0.0327), and high delta (p = 0.0327). Collective implications of the findings of these studies will be discussed.

Stroke survivors often learn to accomplish functional tasks by replacing impaired movement patterns with compensatory ones that are not typically performed by unimpaired individuals. During upper limb reaching movements, stroke survivors use leaning and rotation of the trunk to compensate for impaired shoulder and elbow function. During sit-to-stand movements, lateral displacement and tilting of the trunk is used to decrease weight bearing through the more affected leg. Although compensation can improve task performance in the short term, it may limit recovery in the long term by promoting the disuse of impaired movements instead of their continued practice. Some studies have demonstrated that compensation can be reduced in the short-term through real-time feedback about compensatory movements. However, it is not known whether reductions in compensation learned through feedback are retained beyond a single session of practice. Furthermore, there are no currently available technologies to reduce compensation using widely accessible, low-cost consumer devices. We developed a software tool that delivers real time feedback to help stroke survivors reduce compensatory movements during rehabilitation exercises through webcam-based motion tracking on commercially available devices. In this study, we asked whether a single session of movement training with feedback from this novel tool reduced compensatory movements in stroke survivors, and whether reductions in compensation were retained 24 hours later in the absence of feedback. Sit-to-stand training involved repeatedly standing up from and sitting down onto a backless chair without use of the hands. A reaching exercise involved reaching to touch targets placed on a table in a seated position. During practice, audio-visual feedback about compensatory movement patterns was delivered in real time using a commercial laptop. To measure changes in compensation due to training, participants performed 5 trials each of both the reaching and sit-to-stand tasks, both at baseline and immediately after training, without feedback. In order to measure retention of reduced compensation, participants returned to the laboratory 24 hours later to perform an additional 5 trials of both tasks without feedback. Movement kinematics were measured using 3D high speed marker-based motion capture. Force plates were also used to measure weight bearing through each leg during the sit-to-stand exercise. Trunk displacement and trunk rotation were calculated as outcome measures for compensation during the reaching task. Medio-lateral displacement of the center of mass and the discrepancy in weight bearing between the two legs were calculated as measures of compensation during the sit-to-stand exercise. We report the differences in each compensation metric, relative to baseline, both immediately after training and during the 24-hour retention test.

The few prior studies examining rehabilitation for individuals with brain injury due to hypoxia focused on inpatient rehabilitation. This is the first study to examine admission and outcome data in advanced postacute rehabilitation settings in comparison to participants with TBI and stroke.

Methods: Retrospective analyses of de-identified data from a nationally representative consortium of U.S. postacute brain injury rehabilitation providers for participants in postacute Residential, Home and Community, Day Treatment, and Outpatient rehabilitation programs. Data include 64 participants with hypoxia, 583 with TBI, and 801 with stroke.

Results: Significant differences in age were detected when comparing the participants with hypoxia (mean=45, sd=16) to participants with stroke (mean=58, sd=13), but not TBI participants (mean=44, sd=16) (F=138.91, p<.001). Significant differences in sex were also present with the hypoxia sample having a larger proportion of female participants (39.5%) than the TBI (28.5%) and stroke samples (28.1%) (2=19.2, p<.001). No significant differences were detected when comparing the hypoxia group to TBI and stroke participants on time post-injury and length of stay. On average, participants with hypoxia scored significantly worse at admission and discharge than those with TBI and stroke on the Mayo-Portland Adaptability Inventory (4th edition) MPAI-4 Total score (admission F=12.62, p<.001; discharge F=15.54, p<.001) and most indices and subscales: Ability (admission F=8.13, p<.001; discharge F=14.15, p<.001), Adjustment (admission F=35.17, p<.001; discharge F=12.41, p<.001), Participation (admission F=16.10, p<.001; discharge F=20.17, p<.001), and Cognition (admission F=26.12, p<.001; discharge F=16.01, p<.001). Significant differences between hypoxia and TBI participants were detected on the Physical (admission F=54.10, p<.001; discharge F=54.46, p<.001) and Autonomy subscales (admission F=34.20, p<.001; discharge F=23.83; p<.001), but not between hypoxia and stroke groups. Although significant differences were detected between admission and discharge across the Total score and all indices and subscales for the hypoxia group (indicating improvement), the rate of improvement varied by injury type. Significant differences in rate of change between admission and discharge were detected between the hypoxia and TBI groups on the Total MPAI-4 T-score (F=13.96, p<.001) as well as T-scores for the Ability (F=12.27, p<.001) and Adjustment indices (F=13.58, p<.001) with all differences showing more improvement in the TBI group. A significant difference in rate of change between admission and discharge was detected between the hypoxia and stroke groups on the Autonomy subscale with the hypoxia group showing a smaller rate of change (F=6.35, p=.002). However, effect sizes for these differences in rates of change were small and no significant differences were detected between the groups on the Participation index and the Physical and Cognition subscales.

Conclusions: Individuals with brain injury secondary to hypoxia benefit from advanced postacute brain injury rehabilitation. Outcomes are similar to or only slightly less than participants with TBI and stroke.

Background: Traditional speech-language pathology (SLP) assessments are often not sensitive to the subtle cognitive-communication deficits after childhood traumatic brain injury (TBI). Given emerging research across health-related disciplines, including with adults experiencing TBI, virtual reality (VR) has shown promise for simulating functional settings to flexibly assess complex skills in a short period of time.

Objectives: To describe the design and evaluation processes for a VR-based SLP assessment for cognitive-communication difficulties after childhood TBI.

Methods: The processes included: 1) initial conceptualization, design, and development of the VR prototype in Unreal Engine 5.1 and deployed via a Meta Quest Pro VR headset; 2) an online survey of 31 SLPs related to awareness, opinion, and feasibility of VR in clinical settings; 3) an online survey of 15 SLPs to provide expert input on the VR prototype; and 4) a codesign session with 4 SLP graduate students who trialed the VR prototype in-person. Screenshots or videos (2 minutes long) of the VR prototype will be shared during the presentation dependent on format.


Results: While having generally positive ratings of the potential application of VR to childhood TBI (Mdn = 4 or “agree” on a 5-point Likert rating scale), SLPs in the first survey identified benefits (e.g., ability to simulate functional tasks n = 21, adaptability of environments n = 10) and hesitations/challenges (e.g., client deficits n = 12, safety and ethical use n = 10) with VR. In the second survey, SLPs provided feedback on the alignment of the prototype with established SLP assessments (Mdn = 4 or “agree the assessment helps assess intended subscales” on a 5-point Likert rating scale) and ways to improve the prototype for clinical application (e.g., adding a timer, increasing distractions or background noise). The SLP graduate students rated the VR prototype “above-average to good” (M = 76.88 (SD = 5.54) on the System Usability Scale, provided ways to improve the prototype for usability by clinicians and children (e.g., more tutorials related to VR use), and co-designed an assessment manual to accompany the assessment.

Implications: The findings from the included research development activities and studies demonstrate strong interest in VR-based assessments amongst SLPs and also provide critical insight on designs that could best support clinical practice. Ongoing and planned modifications and expansions to the prototype, as identified through these studies, will be presented to inform design and development of ecologically-valid assessments of children with TBI. Challenges and benefits of the interdisciplinary, co-design process will also be discussed with the aim of supporting other researchers, developers, and clinicians in the creation of VR-based tools for allied health clinical practices serving children with TBI.

Introduction: Mild traumatic brain injury (mTBI) is prevalent in the military. Although previous research has examined the impact of mTBI on return-to-duty considerations and limitations, little is known about its impact on overall physical fitness. A notable problem in conducting such studies is the lack of a pre-injury measure of physical fitness, which limits the ability to identify injury-related declines. OBJECTIVE: To determine whether experiencing an mTBI is related to declines in physical fitness among military personnel taking a standardized fitness test.

Patients and Methods: This was a retrospective analysis of 2014-2020 records from the Military Health System Medical Data Repository and Physical Readiness Information Management System. Navy personnel with mTBI history, with or without loss of consciousness, were included if they had at least one military Physical Readiness Test (PRT) within a year before and after mTBI. The sample analyzed upper body (push-ups, n=2,206), core (sit-ups, n=2,251), bike (12-minute stationary bike, n=713), and run (1.5 miles, n=1,122) components of the PRT separately. Participants with mTBI history were matched to individuals without mTBI history by age, sex, PRT component, and the time from mTBI to PRT. Pre- and post-PRT scores for the groups were compared using a paired t-test, and multivariable linear regression assessed the impact of various factors on score changes. Lastly, the reliable change index (RCI) was calculated for both groups to assess significant changes in PRT scores and compared using a paired t-test.

Results: Overall, there were no significant differences in pre- and post-injury PRT scores between the mTBI and non-mTBI groups. In multivariable linear regression, mTBI was associated with 0.95 fewer push-ups (p=.02), but this was not statistically significant after false discovery rate and Bonferroni corrections. Using an RCI threshold of ≤ -1.96, 44% of the mTBI group worsened in upper body scores, 0.9% in core, 3.2% in bike, and 5% in run scores, but these changes were not statistically different from the non-mTBI group.

Conclusions: The findings of the present study do not support an association between mTBI and declines in physical fitness among military personnel. There are several possible explanations for these findings, including the use of effective post-mTBI rehabilitation protocols, a high level of baseline health in military personnel, and motivation to maintain or return to prior fitness level following injury. In addition, changes to physical fitness resulting from mTBI could be more subtle or occur in shorter term post-injury time periods, and examining these factors requires focused testing rather than the use of existing performance data. Nevertheless, this study provides valuable information that is relevant to military personnel and health care providers, as it could help guide patient counseling on expectations for a return to prior level of functioning.

Introduction: Mild traumatic brain injury (mTBI) and musculoskeletal injury (MSKI) both negatively impact the health and readiness of United States (US) service members. Little is known on whether specific types and locations of MSKIs are more prevalent prior to or following mTBI. Therefore, the objective of this study was to calculate the proportion of MSKI according to location of injury before, concurrent with, and after mTBI among US service members with MSKI. We then compared these proportions to MSKI proportions among those without mTBI.

Methods: This cross-sectional study included 553,318 US service members who joined between 2016 and 2020, sustained an MSKI during service, and had data in the Military Health System Data Repository through 2023. The first MSKI after joining (i.e., incident MSKI) was identified by anatomical complex (location), primary tissue type affected and International Classification of Functioning, Disability and Health codes. Incident mTBI was identified using International Classification of Diseases, 10th revision codes defined by the Armed Forces Health Surveillance Division. We calculated proportions of incident MSKIs and estimated 95% confidence intervals (CIs), categorized by location and timing relative to mTBI. We used chi-squared tests to assess differences in MSKI location by mTBI group.

Results: The average (SD) age at military entry was 20.7 (3.5) years, 78.7% were male, 44.3% were in the Army, and 3.3% sustained an mTBI during the study period. MSKI location differed between mTBI and non-mTBI groups (p’s < .01). Among the 535,199 without mTBI, the most common MSKI locations were ankle/foot (32.7%; 95% CI 32.6-32.9%), knee (23.3%; 95% CI 23.1-23.4%), and lumbopelvic-hip (20.2%; 95% CI 20.1-20.3%). Of the 14,368 incident MSKIs that occurred prior to mTBI, the most common locations were ankle/foot (33.3%; 95% CI 32.5-34.1%), knee (24.9%; 95% CI 24.1-25.6%), and lumbopelvic-hip (19.6%; 95% CI 18.9-20.2%). The most common locations for MSKIs concurrent with mTBI (n = 831) were cervicothoracic related (40.7%; 95% CI 37.3-44.0%), lumbopelvic-hip (13.6%; 95% CI 11.3-15.9%), and shoulder (12.0%; 95% CI 9.8-14.3%). After accounting for MSKIs that occurred prior to or concurrent with an mTBI the most common MSKI locations after mTBI (n = 2,920) were ankle/foot (22.8%; 95% CI 21.3-24.3%), lumbopelvic-hip (21.5%; 95% CI 20.0-23.0%), and knee (18.4%; 95% CI 17.0-19.8%). From pre to post mTBI, the largest difference in proportions were observed for ankle/foot (Δ-10.5%; 95% CI -11.3 to -9.8%) and cervicothoracic (Δ6.9%; 95% CI 6.1-7.7%) MSKIs.

Conclusions: In this study of 553,318 US service members with MSKI, 3.3% of whom had mTBI, the most common MSKIs before and after mTBI were ankle/foot injuries. The most common concurrent MSKIs occurred in the cervicothoracic region. Results highlight differences in MSKIs relative to an mTBI event, which helps us to understand potential mechanisms of injury.

Background: Moderate-severe traumatic brain injury (TBI) can result in persistent cognitive difficulties, particularly affecting executive functions and prospective memory, which impact daily functioning. While traditional paper-and-pencil or computerized neuropsychological tests are generally used, their ecological validity is limited. Virtual reality offers a promising alternative, reducing cost of in-home assessments and enhancing standardization. However, data on the use of ecological virtual reality tests in the TBI population is scarce.

Objectives: The general aim of this study was to examine the validity of the Virtual Multitasking Test (VMT), a multitasking scenario performed in a non-immersive virtual apartment, for evaluating prospective memory and executive functions in adults with moderate-severe TBI and control participants. The specific objectives were to explore associations between performance on the VMT, traditional neuropsychological measures, and measures of user experience (cognitive load, cybersickness, sense of presence), and to examine the discriminant validity of the VMT (i.e., TBI vs control group).

Methods: Fifteen participants with moderate-severe TBI (20% female; mean of 43.5 years; mean of 80 months post-TBI) and fifteen age-, sex- and education-matched control participants were recruited. The experimental visit was divided into two parts: neuropsychological testing (Tower of London, Zoo Map Test, CAMPROMPT, and subjective questionnaires) and virtual reality testing with the VMT. The VMT, averaging 25 min, involves completing tasks that are known in advance (putting away groceries, preparing a recipe, setting the table) and unplanned tasks (e.g., putting a shirt in the dryer), soliciting prospective memory, multitasking, flexibility, and planning abilities.

Results: Significant moderate to large correlations were found between traditional neuropsychological measures (Tower of London, CAMPROMPT) and performance on the VMT (total score, prospective memory score). Better performance on the VMT was also significantly associated with higher perceived cognitive load, but showed not association with self-reported memory and executive functioning, cybersickness, or sense of presence. Regarding the second objective, the VMT total score showed a sensitivity of 80% and a specificity of 73% for identifying participants with moderate-severe TBI. Significant between-group differences were observed on the total score and the prospective memory score of the VMT, with the TBI group showing poorer performance.

Conclusions: The VMT appears to be a valid ecological tool to evaluate cognitive functioning in an adult population with TBI. Diversifying methods to assess executive functioning and prospective memory, including tasks with high ecological validity, may better identify day-to-day challenges in individuals with brain injury.

Introduction: The unpredictable nature of traumatic brain injury (TBI) forces families to adapt to a caregiving role for which they are often inadequately prepared. This can lead to several negative consequences for both the family and the individual living with TBI, such as anxiety, social isolation, reduced mental health and financial difficulties. As the needs of these families evolve beyond the initial rehabilitation phase, it becomes crucial to implement interventions that support families coping with permanent sequelae. Community organizations are well-positioned to provide long-term support to TBI families, but should be guided by evidence-based practices to ensure the effectiveness of their services. SAFIR-E© [Soins Aux Familles : Intervention pRécoce en Équipe] is an interdisciplinary intervention designed for ABI families, including five key components: comprehension of the family ecosystem, emotional support, information dissemination, family engagement, and care coordination. SAFIR-E© could offer a promising solution for delivering tailored and effective support within community organizations but, to date, has only been implemented in acute settings.

Objectives: To explore the key facilitators and barriers to the implementation of SAFIR-E© within a community organization, as perceived by interprofessional community workers and managers.

Methods: Based on a descriptive qualitative design, semi-structured interviews will be conducted with community workers and managers of a community organization in the Vaud region in Switzerland between October and November 2024. A sample of 15 participants is anticipated to be sufficient to reach data saturation. The Consolidated Framework for Implementation Research supported the development of the interview guide. Interviews will be recorded, transcribed (verbatim), and analyzed using both inductive and deductive methods.

Results: Finding from this study will inform the implementation strategies, thereby improving both its acceptability and usability within a new context. The data will contribute to the body of evidence regarding SAFIR-E© adaptation process to effectively implement this innovative practice.

Conclusions: Ultimately, the successful implementation of the SAFIR-E© intervention is expected to limit the consequences inherent in the role of caregiver and support families in their experience by offering them targeted and effective assistance.

Background: Traumatic brain injury (TBI) is a pressing public health concern, with high mortality rates and a significant impact on brain development. It results in a range of emotional, physiological, and cognitive sequelae. TBI accounts for over 400,000 emergency department (ED) visits, 29,000 hospitalizations, and 3,000 deaths annually in US children. This study aims to evaluate trends in fall-associated with TBI in children in Texas. The findings from this evaluation may help stakeholders develop urgent and effective strategies to reduce preventable fall-related TBI incidents.

Methods: A retrospective study of TBI in children ≤18 years was performed using the Texas Trauma Registry (2018-2022). The ICD10-CM and Glasgow coma scale were used to identify TBI cases and severity. The TBI proportion and risk factors were analyzed overall and by age groups (0-4, 5-10,11-13, 14-18 years). Descriptive statistics and logistic regression were performed.

Results: Of 104,908 pediatric trauma patients who arrived at an ED in Texas, 41,402 patients (39.5%) sustained falls, and 16.8% (n=6,943) of them were diagnosed with TBI. 57.5% were male. TBI incidence was higher in males than females (17.4% vs 16.0%, p<0.0001). Falls were highest in age 0-4 (36.5%), followed by age 5-10 years (33.3%), 0-4 years old (28.1%) and 14-18 years old (13.9%). Unintentional falls accounted for 99.5% of pediatric falls. TBI-related falls were not different between urban and rural (12.5% vs 13.5%; p=0.2736). Compared to the 0-4 year age group, increasing age was associated with a lower risk of fall-related TBI by 76%, 73%, and 41%, corresponding to 5-10, 11-13, and 14-18 years old, respectively. Patients with injury severity score (ISS) ≥16 were observed in 57.2% of fall-related TBI patients, and mild TBI (GCS ≥14) was 90.8%. Higher odds of TBI risk were associated with 2.6-, 9.3- and 13.7 times in patients with moderate, severe, and critical injury, respectively, compared to mild injury. The admission of TBI-linked falls increased from 13.4% in 2018 to 22.7% in 2022, with an average odds of a 5% increase per year, although lower incidences in 2020 (12.2%) and 2021 (11.1%). The odds of fall-related TBI were associated with 2.14- and 1.89 times in 2019 and 2022, compared to 2018, respectively.

Conclusion: Fall accounted for about 40% of pediatric patients who arrived at the ED for trauma care, and nearly one-fifth of them were diagnosed with TBI, with a higher incidence in the pre-school-aged group. Trends in fall-related TBI incidence have been increasing. This underscores the need for a united effort from patients, caregivers, and coaches, as well as healthcare professionals, researchers, and policymakers, to develop and implement effective prevention strategies to reduce preventable fall-related TBI incidents.

Introduction: Intimate partner violence (IPV) primarily affects women and gender-diverse people. A recent study found 98% of a sample of 2S/LGBTQ Canadians had experienced IPV in their lifetime (physical, psychological, financial, sexual or identity-based abuse). While IPV can manifest in various forms, physical violence is particularly concerning due to its potential to cause significant harm, including brain injury (BI). Although incidence rates are difficult to determine, various studies have demonstrated 70% of those who have experienced IPV, had symptoms consistent with a BI as a result of physical violence. This potentially indicates a substantial number of 2S/LGBTQ people who may access a service provider organization (SPO; e.g., public, private, and mental-health care, emergency services, domestic violence shelter, victim services) after experiencing IPV-caused BI. 2S/LGBTQ survivors are likely to face unique challenges that limit access to necessary support systems following IPV-caused BI. Addressing gaps within SPOs that hinder 2S/LGBTQ survivors from receiving comprehensive, affirming care requires further investigation.

Methods: To explore the unique challenges and solutions for 2S/LGBTQ survivors who access SPOs following IPV-caused BI, semi-structured interviews were conducted using an interpretive description approach for applied disciplines. Interviews discussed survivor and service provider experiences around 2S/LGBTQ access to SPOs, with a focus on issues and potential resolutions. Interviews were transcribed, de-identified, and analyzed. Line-by-line initial coding was used to group data which was interpreted and mobilized into challenges and informed solutions guided by expert participants.

Results: Eleven service providers and three survivors participated in interviews (N=14; 10/14 (71%) identified as 2S/LGBTQ). The study identified three key challenges 2S/LGBTQ survivors may face when attempting to access SPOs with corresponding solutions. First, most SPOs operate within a cisgender, heteronormative understanding of IPV, making it difficult to recognize IPV and resulting BI within 2S/LGBTQ communities. To amend this, mandatory training and awareness campaigns were suggested as critical steps toward more inclusive care. Second, due to framing IPV in a cisgender, heterosexual lens, 2S/LGBTQ survivors, particularly racialized survivors, often feel excluded and underserved. To address this, restructuring SPOs to create inclusive, intersectional, and trauma-informed services was recommended. Lastly, the compounding effects of adverse social determinants of health (SDOH) further limit survivors’ access to services. Targeted interventions addressing both IPV and the specific SDOH commonly faced by 2S/LGBTQ individuals were suggested to remedy these barriers.

Conclusions: Understanding the challenges 2S/LGBTQ survivors of IPV-caused BI encounter is essential for creating equitable services. Targeted solutions like mandatory 2S/LGBTQ specific SPO training, addressing adverse SDOH, and restructuring services are crucial steps. These real, urgent problems affect the lives of 2S/LGBTQ survivors, who deserve access to comprehensive, empowered, and informed care.

There are numerous challenges to accurate assessment and classification of disorder of consciousness (DoC) because neurobehavioral presentation is prone to fluctuation and can be masked by confounding or co-occurring conditions. Assessing behavioral signs of consciousness in patients with severe brain injuries can be challenging and can lead to a misdiagnosis when no standardized assessment tool is used. Accurate behavioral assessment requires expertise on behalf of the clinician as there is no true measure of consciousness but rather an assessment of behavioral proxies. The accuracy of the assessment is, however, crucial clinically, legally, and ethically. It influences the way the patient’s care will be oriented. Clinicians are challenged by the ambiguity and uncertainty that arises when assessing and treating individuals with DoC. The accuracy and consistency of these assessments are heavily influenced by the setting and environment in which they are conducted, the patient's positioning, confounding factors and their underlying medical conditions. It is thought that using a checklist to prepare the environment and the patient before conducting a behavioral assessment in individuals with DoC is crucial for ensuring the accuracy and reliability of the assessment. A checklist was developed over a period of three years by a group of interdisciplinary clinicians and researchers with expertise in DoC. Once finalized, the checklist along with a survey was sent to clinicians in various clinical settings with a diverse range of experience working with DoC. Participants were asked to utilize the checklist and provide feedback on its effectiveness. Clinicians found the checklist was useful and effective in optimizing patient and environmental conditions prior to completing a neurobehavioral assessment in patients with DoC. The results showed that use of a comprehensive evidence-based pre-assessment checklist may enhance consistency and accuracy of assessment of patients with DoC across the interdisciplinary team and may result in increased advocacy for access to necessary medical and rehabilitation resources shown to improve recovery.

Introduction: Traumatic brain injury (TBI) has emerged as a significant cause of visual dysfunction, with dry eye disease (DED) being a common sequela. Retrospective studies have shown an increased prevalence of DED in patients with a history of TBI as compared to those without. Understanding the underlying mechanisms of dry eye in TBI patients is crucial for improving both diagnosis and management strategies. This presentation explores the complex interplay between the neurological and ocular systems in TBI-related dry eye – reviewing the pathophysiology of dry eye through a case series.

Methods: A case series of patients referred to a neuro-optometry clinic for visual complaints including intermittent blurred vision and photophobia secondary to dry eye after traumatic brain injury are described.

Results: Dry eye was present in this population as objectively diagnosed through slit lamp examination and fluorescein dye staining, with notably reduced tear break up time. The most common symptoms included intermittent blurry vision, photophobia that manifested as discomfort (versus pain) with bright lights and overhead lights, consistent with glare sensitivity, but minimal sensations of dryness or foreign body sensation. Patients noted relief in their symptoms with lubrication with artificial tears.

Discussion: TBI often leads to disruptions in the autonomic and sensory innervation of the lacrimal functional unit, which comprises the lacrimal glands, meibomian glands, conjunctiva, and ocular surface. This disruption impairs tear production and leads to tear film instability, a hallmark of dry eye. The brain’s role in regulating these components is critical, and any injury can alter the delicate balance of tear secretion, composition, and ocular surface health. In addition, TBI affects the blink reflex, reducing blink rate and compromising the even distribution of tears across the corneal surface. This contributes to ocular surface desiccation and further destabilization of the tear film.

Central to the pathophysiology of TBI-induced dry eye is dysfunction within the trigeminal nerve, which carries sensory information from the ocular surface to the brain. Damage to this nerve may result in decreased corneal sensitivity, reducing the feedback necessary for proper tear production and blink initiation, but also underly the absence of patient’s complaining about dryness or foreign body sensation. Neuroinflammation and neurodegeneration following TBI also contribute to autonomic dysregulation, further impairing tear secretion.

In addition to direct neurological damage, secondary factors such as medication side effects, insomnia/sleep dysfunction, sleep apnea, altered environmental exposures, stress, and systemic inflammation also contribute to the onset and persistence of dry eye in this population.

Conclusion: Dry eye following TBI is multifactorial, involving both central and peripheral nervous system disruptions. Understanding these mechanisms allows clinicians to tailor treatments, incorporating neuro-rehabilitation strategies and targeted therapies to improve the quality of life for TBI patients with dry eye.

Objectives: For many patients, mild traumatic brain injury (mTBI) leads to a cascade of adverse consequences that negatively impact the quality of life, including persistent post-concussive symptoms and long-term difficulties with functional and social reintegration. To mitigate these negative effects, research has focused on identifying factors that can help to rapidly target patients at risk of persistent consequences to promote appropriate management. Among these factors, personality traits have emerged as playing a potentially important role in recovery trajectories. However, the existing literature is sparse and focuses almost exclusively on post-concussion symptoms, to the detriment of functional and social reintegration. Nevertheless, given that these reintegration challenges can significantly reduce life satisfaction in post-mTBI patients, they must be addressed. Therefore, this study aimed to identify which personality traits from the Diagnostic and Statistical Manual of Mental Disorders—5 (DSM-5) Cluster C (avoidant, dependent and obsessive-compulsive) predict functional and social recovery between three- and six-months post-injury.

Methods: 65 symptomatic adults with mTBI were recruited between March 2020 and December 2021 at the Montreal General Hospital (MGH) Trauma Center outpatient mTBI clinic. Within the first month after mTBI, participants were asked to electronically complete a questionnaire assessing personality traits, the Millon Multiaxial Clinical Inventory, 3rd edition (MCMI-III). A follow-up telephone interview lasting approximately 15–20 minutes was conducted three and six months after the injury. During these semi-structured interviews, the quality of functional and social reintegration was assessed using the Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). The MPAI-4 is a questionnaire that measures three domains: ability, adaptation, and participation, to identify specific areas of difficulty. Recovery trajectories (favorable vs. unfavorable) were determined based on relative recovery scores derived from the MPAI-4 at both time points.

Results: Comparisons between participants who completed all questionnaires and those who withdrew revealed no significant differences in MPAI-4 total or subscale scores. Similarly, no significant differences were found in the DSM-5 avoidant, dependent, or obsessive-compulsive subscale scores. Binary logistic regressions established that the avoidant (B = 0.031, p = 0.024) and obsessive-compulsive (B = 0.067, p = 0.031) personality scales significantly predicted the recovery group for one of the three reintegration variables, namely adaptation. The higher the patient’s score on the MCMI-III avoidant or obsessive-compulsive scale, the greater the chance of belonging to the unfavorable recovery group. No significant differences were found between the favorable and unfavorable recovery groups regarding sociodemographic and injury-related variables.

Conclusions: These findings suggest that avoidant and obsessive-compulsive personality traits from DSM-5 Cluster C are most likely to contribute to persistent reintegration difficulties following a mTBI, particularly in the domain of adaptation. Early identification of these traits could help clinicians detect patients at risk for poor recovery outcomes, enabling more tailored and proactive management strategies.

Acquired brain injury (ABI) is a significant yet often overlooked factor in violent behaviour, particularly in the context of domestic abuse. Previous research has indicated that ABI is more prevalent among those who have committed violent offences compared to the general population, with some studies suggesting a higher risk of reoffending among those with ABI (Farrer et al., 2012; Williams et al., 2010). This qualitative study explores the experiences and perceptions of practitioners working with individuals who perpetrate violence and abuse, focusing on the prevalence of ABI and its impact on rehabilitation and engagement with services. Semi-structured interviews were conducted with seven practitioners across probation services, prisons, and third-sector organisations, allowing for in-depth insights into the challenges faced when working with this population.

Thematic analysis revealed five critical themes: (1) Lack of training and awareness of ABI, as practitioners often reported feeling unprepared to recognise or address brain injuries in their clients. (2) Resource constraints, which hinder the provision of adequate support and specialised interventions for individuals with ABI. (3) The need for tailored interventions that accommodate the cognitive and behavioural challenges posed by ABI. (4) Identification and screening challenges, with many practitioners acknowledging the absence of formal tools to screen for ABI in violent offenders and (5) The impact of ABI on behaviour, particularly in how it affects the ability of individuals to engage with rehabilitation programmes, leading to higher rates of recidivism. An overwhelming unexpected gap highlighted in this study is that female offenders (who have perpetrated violence) are not supported to identify ABI, nor do they have access to relationship based behaviour change programmes related to violent offences.

Practitioners expressed concerns about the lack of formal training on ABI and emphasised the need for better resources and support systems to address the unique needs of this population. Many reported relying on incidental knowledge or informal briefings, which are insufficient for dealing with the complexities of ABI-related behavioural issues (Farrer et al., 2012). The findings suggest that there is an urgent need for systemic changes, including the introduction of standardised screening tools, improved training for practitioners, and more comprehensive intervention programmes tailored to those with ABI.

Introduction: Individuals aging with a traumatic brain injury (TBI) may face dual stigmatization, ageism and ableism, which can restrict their social participation (SP). SP is associated with a reduced risk of mortality, in addition to being a modifiable determinant of health and successful aging. Interventions supporting SP of individuals aging with TBI remain scarce and poorly documented. It has been shown that intergenerational initiatives improve the health of older adults, support SP, and foster more positive attitudes toward aging. However, none of the studies on intergenerational initiatives have been initiated with the TBI population.

Objectives: (1) Explore the relevance of intergenerational initiatives for individuals aging with TBI; (2) Identify the opportunities and challenges when implementing these initiatives; (3) Identify strategies to evaluate the potential effects of these initiatives.

Methods: This exploratory qualitative study is part of a broader participatory action-research project implementing an intergenerational initiative designed by and for individuals with TBI. Semi-structured interviews (60min) will be conducted with individuals living with TBI (4), community workers working with this population (4) and intergenerational experts (4). An interview guide consisting of 20 questions (including sociodemographic) was co-developed and pre-tested with the steering committee of the research-action project. A mixed-methods approach based on the Framework Method was used for data analysis. The deductive portion relies on the Consolidated Framework for Implementation Research (CFIR).

Results: A total of eight interviews were conducted (4 individuals with TBI, 2 community workers and 2 experts). Among individuals with TBI (2 women, 2 men, on average 20 years post-TBI), three were aged between 63 and 68 years and one was 28 years old. The intergenerational experts (2 women academics) had 8 years' experience in the field. The community workers (2 women) had been working with the TBI population for an average of 8.5 years. A preliminary analysis revealed unanimous agreement on the relevance of intergenerational initiatives, particularly in breaking the isolation of individuals with TBI. All participants evoked multiple and unique challenges linked to TBI, such as cognitive issues, and therefore the importance of adapting the instructions, and having personalized support from community workers. Individuals with TBI reported the importance of listening to their needs and interests when planning intergenerational initiatives. Experts suggested as an evaluation strategy the combination of qualitative and quantitative measures.

Conclusion: This study enhances the understanding of the opportunities and challenges associated with intergenerational initiatives for the TBI population. It will guide future research aimed at developing initiatives that effectively address the unique needs of this population. By fostering connections between generations, such initiatives aim to reduce ageism and ableism experienced by individuals aging with TBI, ultimately supporting a more inclusive environment.

This study compares a standardized research process to an established clinical process for screening and diagnosis of historical mild traumatic brain injury (TBI) during combat deployment in a military/Veteran cohort. Using validated instruments, the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) prospective longitudinal study (PLS) screens for all potential concussive events (PCE) and conducts structured concussion diagnostic TBI interviews. The Veterans Health Administration (VHA) has a similar systematic screen followed by a comprehensive TBI evaluation (CTBIE). We assessed agreement between these two systems and identified features of Veterans negative clinically but positive in research.

VHA data were obtained from VA Informatics and Computing Infrastructure (VINCI) and linked to the LIMBIC-CENC PLS dataset. VHA screen positive for PCE was defined as a positive response for questions one and two (mechanism and immediate TBI signs/symptoms). The PLS identified more positive PCE screens during combat deployment (86% vs. 41%) than the VHA PCE screen with poor overall agreement (Kappa = 0.113). Participants had higher odds of being VHA-negative/PLS-positive if older age, female sex, more years of military service, more months combat deployed, Officer rank, or <50% service-connected disability rating; and lower odds if less education, higher combat intensity, or higher NSI scores. The LIMBIC-CENC PLS method also identified more Veterans with mild TBI during combat deployment versus the VHA CTBIE (81% vs 72%) with minimal overall agreement (Kappa = 0.311). Participants had higher odds of being VHA-negative/PLS-positive for mild TBI diagnosis if never married or Air Force; and lower odds if greater combat intensity.

Compared to the VHA system, the LIMBIC-CENC PLS research protocol identified higher PCE screening rates and more cases of mild TBI during combat deployment. Agreement was better for TBI determinations. Characteristics of PLS-positive/VHA-negative mismatches included demographic variables, military service variables, and current symptom levels. Further research is needed to better understand whether there is a clinical value to adjust the VHA TBI screening process and how these characteristics could be considered. Providers should be aware that some Veterans may have undocumented, positive mild TBI histories even if they underwent screening and/or CTBIE processes.

Patients with mild traumatic brain injury (mTBI, aka concussion) often suffer from persistent post-concussion symptoms (PPCS) that impair cognitive, emotional, and physical functioning. These symptoms are often resistant to standard treatments, which typically overlook autonomic nervous system (ANS) dysfunction that is characterized by sustained sympathetic hyperactivity and poorly regulated heart rate variability (HRV). HRV biofeedback (HRVB) is an intervention that normalizes and optimizes ANS activity. We were recently awarded Department of Defense grant funding to conduct a randomized controlled trial (RCT) to test whether patients in the HRVB treatment group can develop a skill (resonance frequency breathing) that allows them to achieve ‘HRV coherence’ (synchronization of heart rate, respiration and blood pressure) on demand and as needed, to manage PPCS and decrease overall symptom load. Secondary objectives include assessing HRVB's impact on sleep quality and quantity, cognitive function, pain, depression, and post-traumatic stress disorder (PTSD) symptoms. Exploratory outcomes include biomarkers of inflammation and neurotoxicity.

This presentation will describe the methods of our RCT. Participants (n=148; 74 per group) will be assigned to receive either HRVB or a psychoeducational control treatment via a block randomization procedure stratified by sex and military/Veteran versus civilian status. The HRVB group will undergo weekly HRVB training sessions for six weeks, practicing slow diaphragmatic breathing to synchronize HRV and improve ANS function. The control group will receive psychoeducational sessions of equivalent duration and engagement. Outcomes will be measured at baseline, at the end of treatment (week 7), and one-month post-treatment (week 11). We hypothesize that HRVB will enable patients to significantly improve their HRV coherence and reduce PPCS symptom burden compared to the psychoeducation group. We will also evaluate within-group improvements and factors affecting treatment uptake and efficacy. A budget impact analysis and participant feedback will be used to evaluate the feasibility, acceptability, and cost-effectiveness of wider-scale HRVB implementation. HRVB offers a non-invasive, scalable intervention to enhance ANS function and alleviate PPCS, and if our RCT shows its success, HRVB could become a standard mTBI treatment, improving patient outcomes, promoting resilience, and reducing healthcare costs.

Introduction: Participation is an outcome measure used in healthcare, conceptually imbedded in the social environment in which people live. Previous studies identified meaningfulness, self-determination, and a sense of belonging as defining qualities of participation. Participation measures vary in their focus on objective (e.g. independence or frequency) or subjective components, and vary in their included activities, resulting in limitations in comparing outcomes. Most studies show the primary predictors of participation are social factors including race, education, and marital status of the individual with the TBI, rather than injury severity, which highlights the impact of these social determinants of health.

Purpose: This study seeks to explore the relationship between the experience of participation and the social environment to understand disparate outcomes. This study used a social ecological perspective to explore how persons of color with TBI experience participation in relation to immediate support, community, and societal systems.

Methods: The qualitative study interviewed dyads consisting of a person of color with a TBI and a person they identified as important in their lives. The design used stratified purposive sampling across age group, gender, race, and participation outcome score on the PART-O. Data collection included an interview with the dyad and observations on a brief activity, providing dialogic narrative, visual narrative, and behavioral observations.

Results: The first stage of analysis used the themes meaningfulness, self-determination, belonging, (dis)satisfaction, and the social ecological levels of immediate support, community, and society. Variations were identified across all participation qualities. In some experiences, solitary, immediate social environment, and community functioned separately; others chose activities at one level based on another social level. Data reflected a complex interplay between the brain injury and other social and medical issues impacting participation. Gaps appeared between the positive narrative of some persons with TBI and their paucity in participation performance.

Conclusions: The breadth of variation in experiences of participation suggests quantitative measures need to allow for variations. Participation is best understood through both subjective measures, including resilient narratives, and objective indicators of performance. Healthcare practices should incorporate the person’s medical and social complexity into individualized interventions and goals, and programs based on a social model could better address the barriers to participation.

Introduction: Despite COVID-19’s transition to endemic status, it has significantly impacted healthcare systems worldwide. Although more pronounced in the pandemic’s early years, healthcare services, including community care organizations, rapidly adapted to evolving World Health Organization (WHO) protocols and shifting in health and social care policies. In the second year of the pandemic, WHO guidelines’ focus transitioned from transmission prevention to prioritizing vaccine distribution. In Canada, brain injury (BI) associations, key providers of community care services within the not-for-profit sector, were particularly affected. Our previous study found that in the first year, BI associations faced significant challenges in implementing health safety protocols, largely due to the chronic and varied physical, cognitive, and behavioral impairments of individuals with BI.

Objective: This study aimed to explore the challenges faced by community BI associations and the adaptive strategies they made to respond to clients’ needs in the second year of the pandemic.

Methods: This qualitative descriptive study was part of the larger BI Pandemic Preparedness community-based participatory research project and co-designed with executive directors of pan-Canadian BI associations. Using convenience sampling, 26 BI associations were recruited, representing about one-third of all Canadian community BI associations. Data was collected through six virtual focus groups, each involving 4-6 participants and lasting approximately two hours. Thematic analysis was conducted with triangulation of perspectives and multiple researchers.

Results: Themes generated highlight ongoing challenges for BI associations in the second year. Clients with BI faced cascading and growing daily challenges including worsening mental health and insecurity around basic needs as well as continued difficulties in adhering to public health guidelines. Participants also highlighted that people with BI experienced continued barriers to accessing digital health services, which were increasingly being used by health professionals. In response to these challenges and continued changes in the pandemic and in public health and services, BI associations were required to adapt by providing tailored support for vulnerable groups, offering hybrid service delivery, and simplifying safety protocols and vaccination-related information in plain language. Additionally, many BI associations implemented personalized services to address isolation, distress, and varying comfort levels with in-person activities, while pandemic-related grants and funds became scarce. Despite financial challenges, BI associations expanded their services to address broader social determinants of health, such as housing, food security, and substance use, while collaborating with external partners to ensure long-term sustainability. Further, BI associations shifted from crisis management to strategic planning, prioritizing staff well-being, networking, and building resilience as the pandemic continued.

Conclusions: Our findings offer valuable insights for researchers, stakeholders, and policymakers globally, highlighting the importance of enhancing health equity for vulnerable individuals with disabilities and improving preparedness for future crises.

Introduction: The Cognitive Orthosis for coOKing (COOK), is a web-based, context-aware system designed by our team to support individuals with moderate to severe cognitive impairments following acquired brain injury (ABI) in preparing meals safely and independently. This technology includes three components: (1) a sensor-based security system to monitor safety incidents, (2) a cognitive assistance application providing step-by-step instructions via tablet to increase independence, and (3) a configuration system allowing expert clinicians to tailor COOK’s features to individual needs.

Objectives: This study aimed to (a) evaluate the COOK prototype features through stakeholders’ feedback and (b) examine the feasibility of a modified version in an ABI residential community setting as part of the user-centered design process.

Methods: For the first objective, a qualitative descriptive approach was used, involving semi-structured interviews and focus groups with patients (n=20), informal caregivers (n=13), and experienced care providers (n=30). For the second objective, a mixed-methods single-case study approach was applied using the "Fit between Individuals, Task, Technology, and Environment" framework. A participant with cognitive impairments following severe ABI recruited after comprehensive cognitive and instrumental activities of daily living tests. The independence and safety during meal preparation were assessed pre-, mid-, and post-intervention during receiving training sessions for using COOK in a shared kitchen based on three behavior indicators: numbers of required assistance, task performance errors, and responses to safety concerns. These were compared to an untrained control task. Additionally, benefits, barriers, and facilitators of COOK implementation within the residence were explored through interviews with the participant and focus groups with the care team.

Results: At the prototype phase, stakeholders found COOK useful in increasing safety and independence for clients with ABI in both clinical and non-clinical contexts. However, they recommended comprehensive pre-assessment and thorough training by experts for successful implementation. Feasibility testing of the modified version showed a significant increase in independence and safety during meal preparation compared to the control task across all behavioral indicators. The client and care team highlighted COOK’s ability to address cognitive and executive function deficits, but suggested improvements, such as installing COOK within the client’s apartment instead of a shared kitchen and providing a training toolkit for all therapists in the residence. They also recommended combining other compensatory strategies such as memory notes and adding motivational elements, like rewards (e.g., new recipes, budgets), to sustain the client’s engagement.

Conclusion: This study provided valuable insights to stakeholders on implementing cognitive technology in real-world settings for clients with ABI. Future research is warranted on developing a comprehensive training toolkit for end-users and care teams, as well as conducting larger-scale effectiveness studies, building on the lessons learned.