Objectives: Individualized sub-symptom threshold aerobic exercise facilitates recovery from sport-related concussion (SRC) and reduces the incidence of persisting symptoms. No definitive volume or dosage of exercise is known to maximize outcomes or improve adherence. It is also unknown if current recommendations for post-concussive aerobic exercise are equally efficacious in males and females. This study assessed low- versus high-volume aerobic exercise prescriptions for their efficacy in facilitating recovery from SRC in males and females. Additionally, this study evaluated exercise adherence between sexes and groups. Methods: Athletes 6.18 ± 2.21 days of SRC (n= 32, 66% male, 15.6 ± 1.4 yrs) and healthy controls (n= 28, 66% male, 16.0 ± 1.6 yrs) performed a graded treadmill test weekly (Days 0, 7 and 14). Concussed and control participants were then randomly prescribed individualized aerobic exercise at high (5 days/week for 30 minutes) or low volumes (3 days/week for 20 minutes); intensity was based upon 90% of the achieved heart rate on the treadmill test. At-home exercise data were recorded with a Polar heart rate monitor (H10), and exercise sessions were observed through video calls to ensure safety and to confirm Polar exercise log reports. Results: Minimal differences in recovery time were seen on survival analysis among males. Although it did not reach statistical significance (p = 0.058), females in the low-volume group appeared to recover faster during the first four weeks after injury than in the high-volume group. Of the 24 exercise-intolerant participants, 8 were female (73%), and 18 were male (86%). Of the 8 females, 7 (88%) had to stop their at-home exercise sessions early on one or more days due to a more than mild symptom exacerbation increase of VAS by ≥2 points vs. baseline). Conversely, only 3 (17%) of males had to stop an exercise session early on one or more days due to symptom exacerbation (p = 0.002). Furthermore, adherence rates were relatively similar between all groups except that concussed women adhered to high-volume prescriptions less often than control women (17%, 80%). Conclusion: Concussed females prescribed a high volume of exercise took longer to recover than concussed females prescribed a lower volume, which was not seen in males. Symptom exacerbation during at-home exercise may have affected female exercise behavior. Although aerobic exercise benefits SRC recovery, this study highlights the need for future research to optimize exercise treatment prescriptions for females with SRC.

Background: Individuals with traumatic brain injury (TBI) often experience residual mobility deficits that can be improved with treadmill and virtual reality (VR) interventions. However, previous studies have not measured underlying neurophysiology during these interventions nor assessed if acquiring such data is feasible in TBI populations. Thus, the primary purpose of this study was to assess the feasibility of using portable functional near-infrared spectroscopy (fNIRS) to measure neurophysiology during a treadmill task and a treadmill + VR task. A secondary, exploratory aim was to test for possible differences in underlying neurophysiology (i.e., neural activity) during the two tasks.

Methods: This was a single-arm pilot feasibility study that included within-subject fNIRS data acquisition during a treadmill task (TT) and a treadmill + VR task (TTVR), which were completed in a single visit in a hospital setting. All study procedures were approved by the hospital’s institutional review board, and all participants provided informed consent prior to the administration of study measures. Eight individuals with chronic moderate to severe TBI were recruited and completed the study. FNIRS data were acquired with the NIRSport2, which is a fully portable system. The device, which weighs less than 2 pounds, was secured to the participants’ backs with backpack-like straps; this was placed over the safety harness used for the treadmill tasks. Treadmill tasks were completed on the Motek C-Mill™ treadmill and the VR application was Arkanoid. Participants were advised to pick a walking speed that they could maintain for a 12-minute TT and a 12-minute TTVR; the order of tasks was counterbalanced between participants. Once a preferred walking speed was established, participants began either the TT or VRTT with simultaneous fNIRS recording.

Results: Feasibility benchmarks included safety, acceptability, and fNIRS data quality. Safety was assessed by monitoring and documenting adverse events such as falls or near-falls during TT or VRTT. Acceptability was assessed with an fNIRS acceptability questionnaire, which was completed by participants after the TT and VRTT. Finally, fNIRS data quality was assessed by quantifying the portion of participants from whom quality data could be acquired and by assessing the proportion of data files for which standard fNIRS data analysis steps (conversion, spatial registration, and temporal processing – which includes motion correction) could be completed. All feasibility benchmarks were met. The fNIRS protocol used in this study was safe for all participants and acceptable to 87.5% of participants. FNIRS data acquisition and quality benchmarks were achieved for 87.5% participants. Exploratory fNIRS analyses revealed significantly greater neural activity during the TTVR compared to the TT alone (p values <. 05).

Conclusions: Findings indicated that acquiring neurophysiology data, via fNIRS, during treadmill tasks is feasible in TBI. Thus, this fNIRS protocol can be used in future, larger-scale studies.

Background: Improving walking function after an ABI is the most common goal stated by patients and/or caregivers receiving inpatient physical therapy. Walking function (gait speed or timed distance) is a major predictor of discharge disposition and length of stay during inpatient rehabilitation, falls, quality of life, community mobility and mortality. The Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury and Brain Injury by the Academy of Neurologic Physical Therapy (ANPT)- American Physical Therapy Association strongly recommends that physical therapists provide task-specific walking training at moderate to high cardiovascular intensity (75-85% of maximum heart rate or 60-80% heart rate reserve, Ratings of Perceived Exertion (RPE) scale of ≥14/20). Given the strength of evidence in favor of HIT and the recommendation put forward by the ANPT to provide HIT as a standard of care in neurologic rehabilitation, we conducted a knowledge translation (KT) project at our inpatient rehabilitation center.

Objective: To present the findings of the KT project conducted at two inpatient rehabilitation centers from 2019-2024.

Methods: The Knowledge to Action cycle was the theoretical framework. Fidelity was monitored through monthly audits of all discharged patients with acquired brain injury from November 2021- June 2024. Initial audits (2021-2023) were conducted through manual data extraction on 20% of consecutive patients admitted into the Brain Injury Program excluding patients with behavior and/or weight-bearing limitations. Automated audits in 2024 were conducted from a report generated through the electronic medical record on all patients discharged from the Brain Injury Program. For all audits, patients meeting the following criteria were included: >17 years-old, without a disorder of consciousness, length of stay (LOS)>7 days, with a walking goal at admission. Descriptive statistics were used to analyze the sample and frequency of receiving at least one HIT session (HIT+).

Results: For November 2021, Site 1: n=10, average age=67, LOS= 18, 50% HIT+. Site 2: n=9, average age=68, LOS= 15, 44% HIT+. For June 2024, Site 1: n=76, average age=66, LOS=18, 64% HIT+. Site 2: n=63, average age=71, LOS=17. 37% HIT+.

Discussion: Implementation of a new intervention into clinical practice takes time, process, and a team-based approach. HIT has been implemented at both sites from a starting point of no use of HIT, but at different levels of fidelity (Site 1> Site 2). Shifting the audit from a manual to a more automated process has benefits and disadvantages. Automated audits are quicker and are inclusive of all patients meeting criteria. However, an automated audit cannot account for behavior and weight-bearing restrictions, cardiac history limiting HIT or complex medical histories.

Future Direction: Reassess barriers to implementation, assess patient outcomes for walking function and to develop a plan for sustainability.

Background: Research has attempted, without success, to determine the most effective and efficient interventions to address mobility deficits and improve overall quality of life in children with brain injury. This is quite different from the adult neurological patient population, in which a consensus has been reached that high intensity gait training (HIT) is the preferred treatment intervention to yield the greatest mobility gains. It is hypothesized that HIT aligns with a child's natural pattern of movement and play, with periods of high intensity activity throughout the day. This report will describe the feasibility and outcomes of a high intensity gait training protocol completed with five pediatric patients diagnosed with pediatric brain injury.

Case Series: Five pediatric patients, all males ages 6-17, were admitted to inpatient rehabilitation following a brain injury resulting in impaired functional mobility. All five children participated in HIT for one hour, 4-5 days per week, for an average of 11 sessions. Interventions included treadmill ambulation, overground ambulation, and stair climbing, and targeted a heart rate (HR) range of 75-85% age-predicted HR maximum. Outcome measures were performed at admission, weekly, and at discharge. All 5 children also participated in occupational therapy, therapeutic recreation, and speech therapy (as needed).

Outcomes: All children participated in HIT for one hour per day, with an average of 35 minutes of active time per treatment session, with an average of 22 minutes in the target HR zone. All children demonstrated improvements in the Pediatric Balance Scale (PBS) and 10 Meter Walk Test (10 MWT) from admission to discharge. The mean improvement in the PBS was 43 points (admission scores ranging 4-55, discharge scores ranging 49-56), 4 children met the MCD score, and all children scored as low risk for falls at discharge. The mean improvement in the 10 MWT was 0.63 m/s for self-selected speed (admission speed ranging 0-0.6 m/s, discharge scores ranging 0.53-1.01 m/s), and all 5 children met the MCD score. All children participated in HIT without adverse events.

Discussion: This case series demonstrated that HIT is an effective and feasible treatment to be implemented in pediatric inpatient physical therapy rehabilitation. The structure of HIT sessions mirror a child’s typical play integrating short, high intensity intervals with HR reaching up to 90% HR max. This enhanced the therapists’ overall goal of utilizing mass repetition, variable tasks, trial/error, and error-based learning strategies to improve outcomes. Four out of five children that participated in this intervention discharged from inpatient rehabilitation at an independent level, an outcome that superseded the treating clinicians’ expectations. This shows a promising outlook for the future for high intensity gait training and an ever-growing increasing population of children that endure a brain injury throughout childhood and adolescence.

Background: The multifaceted and evidence-based rehabilitation treatment T-ScEmo (Treatment for Social cognition and Emotion regulation) is developed for social cognition disorders. Social cognition disorders include, among others, deficits in facial emotion recognition, and are frequently present in patients with Traumatic Brain injury (TBI). A randomised control trial (RCT) has shown T-ScEmo to be effective in improving facial emotion recognition in patients with TBI for at least five months. To date, it is unknown whether this observation of facial affect can be improved in these patients. Therefore, the aim of this study is to investigate if patients’ gaze behaviour changes after T-ScEmo.

Methods: The current study included 23 patients with TBI, included according to the protocol of the RCT of Westerhof-Evers et al. (2017) of whom 15 followed T-ScEmo and 8 the control treatment Cogniplus. All patients performed the Eckman-60faces-test (EFT) and the, for this study designed, image-driven, Facial Emotional Recognition Task (FERT) pre- and posttreatment. During the FERT, eye-movements were recorded using a faceLAB™ 5.0. eye-tracker. Pre- and postperformances on the FEEST and FERT were analysed with SPSS paired sample t-tests and group differences with independent sample t-tests and mixed-ANOVA. Eye-tracking was analysed with a Linear Mixed Effect model implemented in iMAP4 in Matlab 2024b, in which contrasts were performed on fixation heatmaps.

Results: Pretreatment T-ScEmo and Cogniplus groups did not differ on EFT nor FERT total scores. Posttreatment, the T-ScEmo group did score significantly higher on EFT (total, anger, fear) and FERT (total, anger, disgust, fear, happiness, sadness, shame, and neutral) than the Cogniplus group (p < .05). Interaction effect showed that the T-ScEmo group improved significantly more on FERT-total than the Cogniplus group (p < .05). Eye-tracking results showed significant differences in fixation behaviour for pre- versus post T-ScEmo on FERT: anger, disgust, fear, happiness, sadness, shame, contempt, and neutral. Patients showed more fixation to eyes and mouths and significantly less to the middle of the faces after treatment (p < .05), while the Cogniplus group remained fixating centrally at the faces.

Discussion: This study shows that patients who received T-ScEmo not only improved in emotion recognition but also changed how patients look at facial affect, as the focus shifts towards eyes and mouth. These results bolster the positive effects of T-ScEmo. Moreover, this pledges for a change in patients’ gaze behaviour as a likely mechanism underlying the improved emotion recognition.

Introduction: Acquired brain injury patients (ABI) have cerebral damage occurring after birth (eg., trauma, hypoxia, stroke) that can affect several domains, including cognitive functions. Up to 80% of ABI patients, regardless of their etiology, show attentional deficits that highly impact their quality of life and independence by hampering the execution of daily tasks(1). Generally, attentional deficits in patients with ABI are treated with cognitive rehabilitation(2). However, several systematic reviews(3,4) have cast doubt on its effectiveness by reporting only mild to moderate effect sizes. Given this information and the high relevance of attentional deficits; brain injury research should explore new and more effective neurorehabilitation tools. Among these emerging techniques, neurofeedback (NF) is an established instrument to improve attentional abilities in patients with hyperactivity and attentional disorder(5). NF is an applied psychophysiology technique, that promotes EEG entrainment based on operant conditioning and associative learning, during which a subject receives online feedback on their brainwaves while performing a task, with the goal of normalizing brain oscillations(6).

Methods: This ongoing study aims to validate NF as an attentional rehabilitation tool for ABI patients. It is a randomized-controlled trial with 30 subjects with ABI (with mixed etiologies, matched by cognitive profile and rehabilitation goals) divided in two groups: a) receiving NF and b) control group, receiving standard cognitive therapy. The NF training consists of 12 sessions of 20 minutes that aim to increase β power (ie., 16 – 25 Hz) and decrease θ power (ie., 4 – 7 Hz). The task is based on a visual feedback (ie., video expanding/shrinking). The two groups receive the same amount of intervention hours (ie., NF or cognitive therapy). We assess both behavioral and electrophysiological measures for efficacy (ie., attentional behavioral tests, EEG power and connectivity, auditory P300 evoked potential). Moreover, we also measure transfer to daily life and motivation of the intervention through self-reported questionnaires. We will compare pre-post differences between the two groups.

Conclusions: The present protocol has the potential to expand the available neurorehabilitation tools for patients with brain injury with minimum invasiveness and high accessibility of the technique. Data acquisition is currently ongoing and we will present at the IBIA 2025 conference preliminary results.

Acknowledgements: This work is supported by Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15), Ministerio de Ciencia e Innovación (PID2022-141498OA-I00), Fundació la Marató de la TV3 (60/2023), and European Commission (EU- HORIZON-MSCA-2022-SE01-101131344 and HORIZON-MSCA-2022-PF-01-10110814).

References:
1) Riepe, M. W., et al. (2004)
2) Maas, AI. R. et al. (1997)
3) O’donoghue, M. et al. (2022)
4) Rohling, M. L., et al (2009)
5) Corydon, D. (2007)
6) Marzbani et al. (2016)

Background: Global evidence indicates that one in three women and girls will experience gender-based violence (GBV) at least once in their lifetime. Additionally, the relationship between gender-based and intimate partner violence (IPV) and traumatic brain injury (TBI) has been well-established. Despite this, access to brain-injury-specific and trauma-informed support for survivors remains limited. Cognitive-communication disorders are a common sequela of TBI, and it is recognized that experiences of trauma can also negatively impact communication. This is of particular importance as communication competence is critical for survivors who are often required to intersect with first responders, police, health care providers, and legal systems. In these settings where effective communication is essential, survivors are frequently misunderstood, can experience stigma, and, in some cases, face unbelief. With funding from the Public Health Agency of Canada to WomenatthecentrE, a cognitive-communication rehabilitation program was developed and implemented as part of a larger initiative entitled ‘Cross-Sectoral Solutions: Strengthening community capacity to address the ‘parallel pandemic’ of gender-based violence-related brain injury through a survivor-led support program.

Aim: This novel program aimed to provide trauma-responsive cognitive-communication support and intervention to women survivors of GBV with TBI. An additional aim was to build capacity regarding GBV, TBI and communication among speech-language pathology trainees.

Methods: An eight-week novel group intervention program was developed and implemented by a senior speech language pathologist-clinician scientist along with two graduate speech language pathology students. The program involved weekly sessions of 90 minutes, delivered both in a virtual format and in-person to allow for maximum participation. The group size ranged from 4 to 8 participants, with 20 participants in total. The program consisted of education regarding TBI and communication, the impact of trauma on communication, strategies for managing cognitive-communication disorders, as well as an adaptation of Nonviolent Communication: A Language of Life (NVC; Rosenberg M, 2015), and the implementation of breathwork. Objectives for each session were clearly outlined, homework was provided each week for practice, and participants were sent therapy materials in advance of each session. Participants were invited to provide anonymous feedback after each session, and suggestions were incorporated in real-time for subsequent sessions.

Results: The program was generally very well received by participants, who were also considered experts and co-creators in the process. Participants commented that the program would benefit from being longer than eight weeks, and differences were noted between the in-person and virtual groups. Qualitative feedback supported the value and importance of this comprehensive and trauma-responsive program.

Conclusions: There is a critical need for trauma-responsive rehabilitation programs to address the pandemic of GBV and TBI, as well as to build capacity among rehabilitation clinicians. Considerations, successes, lessons learned, and future directions for scaling up the program will be presented and discussed.

It is estimated that at least 1 in 20 Canadian Armed Forces (CAF) service members have sustained a traumatic brain injury (TBI) during operational duty (Garber et al., 2014). Many more engage in high-risk activities during individual and collective training: unarmed combat training, pugel fighting, tactical landings, small boat teams in aggressive waves, and routine use of large-caliber munitions all present situations that can transfer force to the brain. Royal Canadian Mounted Police (RCMP) also engage in high-risk training activities. Many Canadian veterans do not seek help for mTBI symptoms. Veterans might not seek help because they are not aware that the symptoms they experienced were from TBI, believe their cognitive challenges are from PTSD, feel that brain injuries are just part of regular military challenges or are only associated with combat, or perhaps most likely, are committed to mission first and consider themselves last. Overall, the estimated prevalence is likely to underestimate the true prevalence of TBI among CAF and RCMP veterans. An RCT of cognitive rehabilitation for military mTBI, the Study of Cognitive Rehabilitation Effectiveness (SCORE) (Cooper et al., 2017), resulted in reductions in functional cognitive complaints. With colleagues from SCORE, we developed a streamlined version of SCORE that retained effective ingredients from the original, was structured to maximize treatment dose over a short time, and could be delivered in person or virtually: Symptom-Targeted Rehabilitation for Concussion (STAR-C). STAR-C is a 4-week, strategy-focused intervention aimed at improving everyday cognitive function, delivered by trained speech-language pathologists or occupational therapists. In a U.S. pragmatic trial, STAR-C was rated as acceptable, appropriate, and feasible by clinicians, veterans, and active duty service members. We adapted STAR-C for the Canadian context, and enrolled 56 Canadian RCMP and CAF veterans in a randomized feasibility and acceptability clinical trial of STAR-C vs. education. Of 24 participants who completed the treatment arm, 19 completed final ratings, and of those 95% “agreed” or “completely agreed” that the treatment was appropriate, acceptable, and feasible. Of the 28 veterans in the treatment arm who completed the COPM, 60% reported better everyday function. Implications for future clinical intervention will be discussed.


References: Cooper, D. B., Bowles, A. O., Kennedy, J. E., Curtiss, G., French, L. M., Tate, D. F., & Vanderploeg, R. D. (2017). Cognitive Rehabilitation for Military Service Members With Mild Traumatic Brain Injury: A Randomized Clinical Trial. J Head Trauma Rehabil, 32(3), E1-E15.
Garber, B. G., Rusu, C., & Zamorski, M. A. (2014). Deployment-related mild traumatic brain injury, mental health problems, and post-concussive symptoms in Canadian Armed Forces personnel. BMC Psychiatry, 14, 325.

Introduction: Between 30 to 70% of people living with acquired brain injury (ABI) experience challenges with managing finances, which can affect financial and general wellbeing. Yet, there is a dearth of evidence for financial empowerment programs for adults living with ABI. A recent focus-group study identified ABI-sensitive financial coaching (FC) as a critical intervention wanted by people living with ABI. However, there is only one published study, from 2012, related to FC for adults living with ABI.

Objective: To examine participation and outcomes for adults living with ABI in an ABI-sensitive, goal-oriented, and metacognitive strategy-based FC program.

Methods: This mixed-methods and pre-post intervention pilot study analyzed quantitative and qualitative data about a novel FC program and included adults (age 18+) living with ABI. Participants could include a close-other support person. This program included up to 10 sessions and was developed using modified Cognitive Orientation to Occupational Performance (CO-OP) and trauma-informed approaches. Participants addressed two financial-related goals during sessions that were led by occupational therapists trained in the CO-OP approach and financial empowerment facilitation. Modified versions of the Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS) provided quantitative goal-attainment data. Post-program individual interview data was collected from all participants and close-others. Interviews explored program usefulness, meaningfulness, strengths, and possible program improvements. Interview data was analyzed using a content analysis approach.

Results: The five participants included three men and two women (age in years range: 37-72; years post-ABI range: 3-18). Two participants had close-others involved (one spouse; one common-law partner). Four of the five participants completed their FC sessions; one ended participation after four FC sessions but provided post-program data. Seven of the eight total goals (87.5%) across the four participants who completed the FC sessions were achieved in the program. Three participants scored their goal attainment after the program on the modified GAS as the highest possible score (i.e., +2, goal met much better than expected) on at least one of their goals. For pre-post change scores on the modified COPM, three participants had an average performance change score of 2.5 or higher, and four participants had a positive goal satisfaction score change, ranging from +1 to +8. Qualitative data demonstrated that the four participants who completed the program felt the program was useful, meaningful, and feasible. They felt empowered and adequately supported to meet their goals and they liked the structure of the program. However, they thought sessions should have been more spread out.

Conclusions: The results demonstrate initial support that an individualized FC program is well-equipped to support adults living with ABI to meet their financial-related goals. Future research should explore FC findings in larger samples and explore program cost-analysis and future tele-intervention approaches.

Purpose: Persisting symptoms following a concussion can result in cascading negative consequences that impact a person’s ability to resume pre-injury activities and life roles. These significant life changes can place individuals with post-concussion syndrome at risk for a disrupted sense of purpose in life. Addressing purpose disruption is an important goal of person-centered rehabilitation, since living with a sense of purpose in life is associated with a number of benefits to wellbeing and is considered a modifiable health risk factor. The current study examines the feasibility and preliminary efficacy of a purpose renewal intervention for adults with post-concussion syndrome who endorse a sense of purpose disruption in the aftermath of their injuries.

Methods: Participants with persisting symptoms of concussion completed the Compass Course (CC), a twelve-week group-based purpose renewal intervention. Participants completed a battery of pre- and post-intervention measures that assessed concussion symptomatology, sense of purpose in daily life, and life engagement. Following the conclusion of the intervention, participants completed experience surveys and participated in a focus group.

Results: Thirty-seven participants enrolled in the study, and twenty-two participants fully completed the CC intervention. Participants who completed the intervention were significantly different from those who withdrew on age and work status, but not on other measured characteristics (e.g. other demographic factors, severity of concussion symptoms, degree of functional impairment). Participants who completed the intervention (“completers”) were one year post-concussion, on average, with scores on a measure of concussion symptomatology suggestive of significant limitations in ability, adjustment, and participation in daily activity. Nearly all (21 out of 22) completers reported that the CC intervention was acceptable, with high ratings for the intervention’s helpfulness and high ratings for overall satisfaction. Completers demonstrated statistically significant pre-post intervention change across all outcome measures (sense of purpose in daily life, life engagement), with maintenance of this positive change at two-month follow up. Qualitative data from the post-intervention focus groups suggest that purpose renewal intervention is of strong interest in this population, but that the CC would benefit from modifications to increase its acceptability and efficacy for adults with persisting symptoms of concussion.

Conclusion: The CC is a promising and novel intervention for addressing purpose disruption after brain injury. Future work will adapt aspects of the CC to better align with the needs of adults with persisting symptoms of concussion.