Background: Executive functioning and self-awareness may be significantly impaired in individuals with mild traumatic brain injury (TBI), compromising social well-being and quality of life. According to established TBI treatment guidelines, metacognitive strategies are recommended to increase motivation, awareness of strengths and deficits, and strategies for increased attention. However, there is limited data on their efficacy. We report preliminary results from a controlled trial of computerized cognitive training with metacognitive strategies paired with non-invasive brain stimulation in Veterans with mTBI.

Methods: Participants were aged 18-69 years, had suffered a mild TBI, and all had subjective post-TBI cognitive deficits. All participants received sixteen 10-minute sessions of repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (TDCS) or sham combined with 30 minutes of attention processing training (APT-3). During APT-3, participants were scored on a 100-point scale in the following attention processing domains: 1) sustained attention, 2) selective attention, 3) working memory, 4) suppression, and 5) alternating attention. Preset metacognitive strategies were introduced or revisited following each completed session to reinforce their use within the study and also emphasize self-awareness in the participant, making these strategies more generalizable. During each session, the use of metacognitive strategies was recorded and classified by research staff (e.g., skills of task completion, motivation/self-efficacy, task understanding). The correlation between the number of metacognitive strategies used, task accuracy, and global impression of change was calculated for the global cohort.

Results: Eight participants were included in the analysis. Participants improved in all domains of APT-3 (with an average of2 84.2% accuracy score at session one and a 96.8% accuracy score by session 16). Increases were seen in all individual domains (suppressed attention 86% to 97%, alternating attention 66% to 94%. selective attention 61% to 100%). Additionally, it seems that there is a correlation between improved accuracy scores and increased use of metacognitive strategies as the participants applied on average 2 to 3 more strategies while completing attention processing training. The study is ongoing and as we continue to collect data, we will follow these trends and determine their significance in addition to determining if there is an additional correlation with perceived improvement from the global impression of change questionnaire. This continued analysis could help validate the claim that metacognitive strategies could help improve cognitive rehabilitation for individuals with traumatic brain injuries.

Introduction: Traumatic Brain Injury (TBI) affects millions of individuals worldwide and is the leading cause of death and disability. Healthcare systems have traditionally structured and maintained TBI care using a medical expert framework, where clinicians direct the care of their patients and use their expertise to make key clinical decisions with limited input from the 'patient.’ In this framework, the way in which care is delivered is often more to the convenience of the clinician. The assumption that the clinician always “knows best” often leaves patients and their families without agency or investment in their recovery.

Objective: Co-create patient-centered clinical guidance: (1) a TBI Guideline – evidence-based recommendations that help guide clinical decisions and (2) an Ideal Care Pathway – standardized approach for TBI care across the different care stages (pre-acute, acute, specialized care/management, and community) – that prioritize patient agency and collaboration.
Methods: The development of the Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe TBI and the Neurotrauma Care Pathways' Concussion and Moderate to Severe TBI Ideal Care Pathways employed a rigorous multi-step approach that prioritizes voicing the rehabilitation and recovery needs of Persons with Lived Experience (PWLE) to healthcare professionals, managers, and support workers. At each stage of the Living Guideline and Care Pathways activities, PWLE were engaged to (1) identify priorities and gaps in TBI care and (2) review, evaluate and co-create recommendations and updates. PWLE are key partners and members of the Guideline Expert Panels and Neurotrauma Care Pathways’ Steering Committee. Their perspectives are integrated alongside expertise from clinicians, researchers, and healthcare funders. A feedback validation process is implemented after each formal consultation; this involves providing group or individual summaries to PWLE to ensure that all key messages have been accurately represented and to allow for further input and/or necessary changes to be made.
Results: The co-created Living Guideline recommendations and Ideal Care Pathways address the real-world needs and priorities of PWLE and enhance shared decision-making and patient engagement. Guideline recommendations have been added to ensure the agency of PWLE is cultivated during acute and rehabilitative care and that hope for continued recovery after discharge is instilled. Consensus recommendations are divided into sections addressing priority areas for PWLE where high level research evidence is not common (e.g., sexuality and intimacy, peer support for PWLE, family members and caregivers). Key outcomes include (1) PWLE feeling more respected and involved in their care journey and (2) clinicians gaining practical tools to support a patient’s ownership of their recovery.

Conclusion: This shift in process and clinical guidance to patient engagement and co-creation represents a critical advancement in patient-centered TBI care, empowering patients, improving recovery outcomes, and fostering collaborative relationships between clinicians and patients.

Introduction: Sport-related concussions (SRC) in contact sports like football pose a significant risk due to their potential for long-term cognitive and neurological consequences. While head acceleration events (HAEs) are well-documented through sensors measuring head kinematics, the mechanisms that lead to SRC remain poorly understood. Despite significant research on SRC in professional and collegiate American football, a gap remains in understanding this injury within Canadian collegiate football, particularly in identifying key predictors of SRC risk. Accordingly, this study integrates sensor data and finite element analysis (FEA) to develop concussion risk models specific to Canadian collegiate football players.

Methods: Western University football players’ HAEs were recorded during games and practices using helmet-mounted sensors. A retrospective chart review identified athletes who received a SRC diagnosis during the study period. Of these, 45 HAEs were identified that resulted in a SRC. A set of four non-concussive HAEs per SRC, representing the full spectrum of HAEs, was randomly selected using tertiles of linear and rotational brain injury metrics. Each HAE was characterized using Head Injury Criterion and Brain Injury Criterion (BrIC) brain injury metrics, as well as Peak Linear Acceleration (PLA), and Peak Rotational Velocity. The HAEs were simulated using FEA with the Global Human Body Models Consortium 50th percentile adult male head model. This analysis provided estimates of the 95th percentile maximum principal strain (MPS) across various brain regions and calculated cumulative strain damage measure (CSDM) at multiple thresholds. Univariate logistic regression analysis assessed the relationships between various brain injury metrics, brain strains and the likelihood of concussion.

Results: Univariate logistic regression identified BrIC as a strong predictor, with an odds ratio (OR) of 1.12 (95% CI: 1.08 – 1.15) per 0.01-unit increase with a 50% probability of concussion (50POC) at 0.46. The model demonstrated strong predictive power with an area under the receiver operating characteristic curve (AUROC) of 0.929, and a Nagelkerke’s Pseudo R2 of 0.565. Cerebellar MPS had an OR of 1.60 (95% CI: 1.41 – 1.82) per 0.01-unit increase and a 50POC at 0.10 (AUROC = 0.907, R2 = 0.49). CSDM10 showed strong predictive power with an OR of 1.08 (95% CI: 1.06 – 1.10) per 0.01-unit increase and a 50POC at 0.53 (AUROC = 0.919, R2 = 0.57). All predictors investigated achieved AUROC above 0.900, except the PLA (AUROC = 0.889).

Discussion: The findings indicate that specific head kinematic metrics and brain strain outputs from FEA are effective predictors of concussion in Canadian collegiate football. These results highlight the importance of head kinematic-based injury metrics and strain measures in concussion risk modeling. Future research should focus on integrating these biomechanical predictors into comprehensive risk assessment tools. The development of these predictive models could enhance injury prevention efforts in contact sports.

Testimonies of lived experience are a powerful way to gain insight into traumatic brain injuries (TBI), providing a voice for assisting researchers, health service providers and public health advocates. Their perspectives create holistic approaches in understanding health and social outcomes. This raises an important question: what happens when someone on the research team fits all three roles—being a researcher, a service provider, and having lived experience? This someone is me. Having experienced a TBI in early adolescence, I now work in TBI service provision and engage in TBI research. Researchers with lived experience offer “experiential knowledge”, an understanding that each TBI comes with a unique set of circumstances, shaping health outcomes. Sharing experiential knowledge pushes the public health community to acknowledge recovery is not limited to clinical outcomes, but also hidden social impacts of TBI. In sharing their perspectives, they enable non-TBI researchers to gain deeper insight into what constitutes a meaningful recovery. My own TBI shaped how I understand research I conduct and the TBI-specific yoga program I implement in a neurorehabilitation centre. These elements—research, lived experience, and program delivery--function as a system, each influencing, interacting and driving each other. Personal experiences inform highly empathic interactions with patients, survivors, and their caretakers. Researchers with lived experience carry their perspectives as they interact with patients and survivors in a way that is personal—they have a different understanding of TBI and recovery challenges that accompany it. These researchers can approach TBI survivors with sensitivity and authenticity because of their shared experience. When considering TBI recovery, researchers with lived experienced that also work in the sector become an asset in how their perspectives prioritise meaningful recoveries--a recovery in which people’s personal goals and needs are being met. In meaningful recoveries, individuals select activities they prefer, choose work pathways that bring a sense of purpose, and form genuine connections post-injury. Rather than “moving on”, individuals with TBI learn resilience is different than recovery—it’s about moving forward into a life they want to lead post-injury in the face of changes from their pre-injury self. While addressing basic needs is essential, there is an opportunity to create public health policies that move towards empowering individuals in finding their meaningful recovery. By creating supportive environments for individuals with TBIs that are inclusive, community-centred, and promote TBI-awareness, the community and TBI individual mutually benefit. When society reframes people with TBI as capable it changes how we in the TBI community view ourselves. Despite what we know, we are missing opportunities to create policy that promotes genuine societal inclusion. This reinforces the importance of keeping researchers with a unique voice in the form of personal triangulation involved in research, policy and advocacy.

A 41 year old female with a past history of heart failure and left MCA stroke with residual aphasia presented to an acute care hospital with altered consciousness and left sided weakness. Imaging revealed a right MCA M1 occlusion. After thrombolytic therapy she underwent a mechanical thrombectomy with TICI 2b reperfusion. Three days later, she developed postoperative malignant cerebral edema requiring emergent decompressive hemicraniectomy. She was subsequently transferred to a long-term acute care hospital, followed by inpatient rehabilitation hospitalization three weeks after initial stroke onset. Upon admission to the rehabilitation hospital, she was unable to understand spoken words, though her ability to communicate through written language remained intact. Additionally, she presented with left hemiparesis and impulsivity. Audiometry was performed due to concerns of primary hearing loss, revealing no response to sound up to 120 dB despite normal otoacoustic emissions, suggestive of a central cause of her hearing impairment. Communication via written language with a computer tablet continued throughout admission. Reevaluation of hearing function about one month later revealed significant improvement in hearing. The patient was discharged home with a sound amplifier to use as needed. DISCUSSION: Central hearing impairment after stroke is rare but is most commonly observed in cases with bilateral lesions interrupting the ascending auditory pathways in the temporal lobes or subcortical regions. Deficits usually include speech comprehension, spontaneous speech, and hearing sensitivity while reading comprehension and spontaneous writing remain intact. In patients with impulsivity and difficulty communicating post-stroke, culprits such as aphasia, anosognosia and apraxia are typically suspected. However in patients with bilateral lesions, central hearing impairment should be considered.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderateto-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (less than 19 years old) moderate-to severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health management. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Objective: To present chiropractic cranial care of a 15-year-old patient suffering from unresolving post-concussion syndrome secondary to multiple head trauma while playing high school football (North American). American football is the most popular sport among males in the United States and has one of the highest concussion rates among high school sports.

Clinical Features: A 15-year-old patient presented to this clinic having suffered a concussion 6months prior describing multiple impacts to his body and head during a game. He noted his symptoms started with “bad” headaches but later to include photophobia and hyperacusis. At his initial office visit his headaches were constant and worse in the morning localizing bilaterally to the region of the sphenoid greater wings. He was taking Topamax to control his pain and reported a past history of orthodontic treatment. He was deeply concerned because his condition was not responding to rest or medication and his quality of life and activities of daily living were severely compromised.

INTERVENTION/ METHODS: The patient was treated at this clinic for chiropractic cranial care over two-months for 12office-visits. Chiropractic treatment included prone pelvic wedge (block) placements to treat pelvic torsion. Treatment as well focused on chiropractic manipulative therapy to the cervical and thoracic spine regions. Chiropractic cranial therapy determined a left sided temporal bone imbalanced function, which was treated.
During his assessment it was determined a referral to a functional optometrist for vision therapy exercises was necessary and also referred to a dentist to help balance his temporomandibular joint (TMJ) occlusal and condylar function. The dentist worked closely with this office so that following spinal and cranial treatments he would immediately be seen by the dentist, three-visits over one-week. The dental care involved use of a lower occlusal splint to control the patient’s excessive clenching, aggravated by the concussion. LiveO2 (hyper-oxygenation) therapy was also instituted to increase oxygenation aiding brain function and improving his outcome.

Outcome: One-month following instituting care at this office the patient reported he was only experiencing relatively slight deficits in impaired memory, difficulty concentrating, brain fog, fatigue, and apathy, and reported his other symptoms were greatly reduced so that he was no longer taking medication. At the two-month mark he was re-examined (12thoffice-visit) and was only experiencing a slight headache and fatigue after physically exercise. At the six-month and one-year follow-up check in, the patient had started back to full physical activity and returned to playing football, though was cautioned due to possibility of recurrent head trauma and subsequent concussions.

Conclusion: This case represents a 15-year-old male patient’s response to novel interdisciplinary care of his prior unresolving post-concussion syndrome symptoms. Further research is needed to determine what subset of pediatric patients with head trauma.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) acquired pandemic status in early 2020 (WHO, 2024). Symptoms include fever, cough, sore throat, congestion, shortness of breath, fatigue, aches, headache, anosmia, ageusia, and nausea (CDC, 2022). Neurological manifestations such as confusion, stroke, and seizure as well as psychological symptoms are documented for persons with more severe cases of SARS-CoV-2 (García‐Sánchez et al., 2022; Hosp et al., 2021) and/or geriatric populations. Cognitive difficulties associated with SARS-CoV-2 infection are theorized to involve neuroinflammation, hypoxia, dysregulation of the hypothalamic-pituitary-adrenal axis, neurological disruption, and organ damage (e.g., Iadecola et al., 2020; Jaywant et al., 2021). Cortical changes following SARS-CoV-2 infection may occur and cognitive changes may persist beyond the duration of recovery from other symptoms.

Objective: This systematic review explored the emerging literature of neurocognitive symptoms and the duration of symptoms for persons with long-COVID (i.e., > 3 months of symptoms) in adults younger than 65 years.

Methods: The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) protocol. PsychARTICLES, PsycINFO, Healthsource, and Medline databases were searched with term combinations focusing on cognition (i.e., working memory, executive functioning, etc.) and long-COVID (post-infection, post-COVID, COVID-19, coronavirus, SARS-CoV-2) and so forth. Inclusion criteria: (1) published in a peer-reviewed journal, (2) in English, (3) a North American study (due to potential virus variants), (4) between March 11, 2020, and June 3, 2023, (5) focused on cognitive functioning of persons diagnosed COVID-19 positive at least 3 to 4 weeks prior to enrollment, (6) primarily adults between ages 18-65 years, and, (7) quantitative. Studies underwent quality assessment via two independent reviewers.

Results: A total of 3827 articles were identified (632 duplicates) with 3152 screened via title and abstract whereby 549 studies met inclusion criteria (523 were excluded due to reasons of irrelevant outcomes, published outside of North America, study design, no data provided, not published in English, paediatric/geriatric population, did not include long COVID participants, and/or was meta-analyses/review). A total 24 studies published in North America were included in this systematic review (14 cohort, 3 longitudinal, 4 cross-sectional, 2 repeated measures, and 1 case study) with a total of 307,051 participants (Mage 50.7 years). Average time since SARS-CoV-2 infection was 9.5 months with COVID-19 diagnosis and/or report predominantly confirmed through PCR, antigen test, and/or medical professional. Overall, 8-50% of participants experienced significant neurocognitive changes (via both objective [i.e., WAIS-IV; MoCA] neurocognitive and subjective measures) most commonly poorer memory, difficulty sustaining attention and concentration, brain fog and reduced executive functioning skills with many difficulties persisting months postinfection.

Conclusions: Little is known about the persistence of long COVID difficulties, though the current systematic review revealed that neurocognitive symptoms may continue beyond 18 months which has implications for cognitive neurorehabilitation.

Introduction: Globally, an estimated 44% of women have experienced intimate partner violence (IPV) and as many as 75% of those having experienced physical violence sustain a traumatic brain injury (TBI) secondary to blows to the head, face and neck, making the intersection between IPV and TBI a vastly underestimated public health problem. Considering the multiple service sectors involved in responding to the needs of these women, previous studies have shown the need for cross-pollination of knowledge across service sectors and system-level support for integrated and coordinated care. However, little is known about the application of these proposed best practices in the current system of care. In Quebec, Canada, services involved in addressing IPV are done in silos, and the screening for possible TBI in this population is lacking, thus hindering access to adequate services. This study aimed to (1) explore the challenges faced by key service providers in Montreal, Canada, in addressing the complex needs of women victims of intimate partner violence (IPV) with possible traumatic brain injury (TBI), and (2) examine the collaboration, or lack thereof, between these service sectors.

Methods: This study is part of a multi-step, community-based participatory research project. In this preliminary phase, data were collected by an occupational therapy student and a law student through field observations and individual interviews with stakeholders across healthcare, law enforcement, local police, and community services. Data were analyzed thematically.

Results: Findings highlight two key issues: the lack of services that address both IPV and TBI and the difficulties in fostering collaboration between sectors. Gaps in communication, coordination, and mutual understanding across sectors, including healthcare, community, and socio-judicial services, limit the effectiveness of interventions. Although some service providers offer direct support to women victims of IPV, TBI is frequently overlooked or misdiagnosed resulting in inadequate treatment. Moreover, many victims are unaware that they may have sustained a TBI until they are thoroughly evaluated by trained professionals.

Conclusion: This study suggests that restricted access to adequate services for women with possible TBI following IPV is mainly caused by a lack of knowledge about the intersection between TBI and IPV, and a lack of integration between socio-legal, community, and healthcare sectors. Raising awareness across IPV and TBI services of the need to strengthen collaborative approaches across service sectors to establish points of liaison should be deemed essential by all involved services to move towards an adequate ecosystem of support for women with TBI and IPV.

Background: Recovery time following concussion has previously been demonstrated to vary by sex. Time to clinic presentation may influence timing of treatment initiation and thereby affect concussion recovery outcomes. Therefore, the aim of this study was to investigate the relationship between sex, time to clinic presentation, and recovery time. We hypothesize that time to clinic presentation may modify the relationship between sex and recovery time.

Methods: We conducted a secondary analysis of existing clinical data from a cohort of patients treated in a single specialty concussion clinic at a tertiary care center between 2017 and 2019. Patients ages 6-24 years diagnosed with concussion were eligible for inclusion if their initial clinic visit occurred within 3 weeks from the date of injury. Unadjusted Kaplan Meier survival curves were used to display time to clinic presentation and time to recovery by sex, censoring at date of last clinic visit if lost to follow-up. To test the association between time to recovery and sex, we conducted three separate cox proportional hazard regressions to estimate hazard ratios (HR) with 1) sex as the primary exposure, 2) sex while adjusting for age, concussion history, symptom severity, and distance from the clinic, 3) sex while adjusting for days to clinic presentation, age, concussion history, symptom severity, and distance from the clinic. We determined models significant if 95% confidence intervals (CI) excluded 1.

Results: A total of 486 patients (15.5 ± 3.1 years; 285 males, 58.6%) presenting to the clinic within 20 days. Unadjusted cox regression revealed females had slower recovery (HR: 0.70, 95%CI: 0.56,0.86) than males. When adjusting for age, concussion history, symptom severity, and clinic distance females had slower recovery than males (aHR 0.80, 95% CI: 0.64,1.00). When adding days to first clinic visit as a covariate sex differences were null (aHR: 0.91, 95% CI: 0.73, 1.13).

Conclusions: Males and females treated at a specialty concussion clinic displayed overall differences in recovery outcomes, aligning with prior research suggesting females exhibit slower recovery outcomes. However, when adjusting for notable covariates, specifically time to clinic presentation, there were no significant sex differences. These findings suggest a potential sex-based disparity in post-concussion healthcare activation and highlight opportunities to improve concussion outcomes.

Background: Head impacts in soccer have been associated with both short- and long-term neurological consequences. Youth players’ brains are especially vulnerable given that their brains are still developing. Approximately 90% of head impacts in soccer occur from purposeful heading. Kinematic head impact magnitudes differ depending on the type of kick they originate from. Brain strain, a measure of brain damage, is correlated with kinematic head magnitudes.

Purpose: Accordingly, this study assessed the relationship between type of kick and brain strain during purposeful headers in male youth soccer players.

Methods: A prospective cohort study of a single elite male under-13 youth soccer team of 18 players (two forwards, nine midfielders, five defenders, two goalies) was conducted for one playing season. Players wore instrumented mouthguards to quantify head impact magnitudes during practices and games. Purposeful heading events were categorized by type of kick (e.g., deflection, punt, free kick, throw-in, pass in air, other) for 49 practices and 23 games. Finite element model simulations with the Global Human Body Models Consortium 50th percentile adult male head model were performed on each of the headers to calculate average (MPS) and 95th percentile (MPS95) maximum principal brain strain. Linear mixed effects models evaluated whether type of kick predicted brain strain with individual and event differences entered as random effects.

Results: A total of 362 head impacts were measured during the season, 125 of which occurred during games and 237 during practices. The median (IQR) linear acceleration and rotational velocity of all head impacts was 14.7 (7.2) g and 7.5 (8.8) rad/s. Type of kick significantly influenced MPS (F5=2.91, p=0.014). Punts (0.072, 95% CI [0.055, 0.089], p = 0.016), free kicks (0.064, 95% CI [0.055, 0.073], p = 0.006), and passes in air (0.060, 95% CI [0.054, 0.067], p = 0.003) significantly increased MPS compared to deflections (0.051, 95% CI [0.045, 0.058]). Type of kick also significantly influenced MPS95 (F5=2.42, p=0.037). Punts (0.143, 95% CI [0.108, 0.177], p = 0.019), free kicks (0.123, 95% CI [0.104, 0.141], p = 0.022), and passes in air (0.119, 95% CI [0.106, 0.131], p = 0.006) significantly increased MPS95 compared to deflections (0.101, 95% CI [0.088, 0.115]).

Conclusion: These results suggest that certain types of kicks such as punts, free kicks, and passes in the air pose a higher risk for increased brain strain in youth male soccer players, which could have implications for injury prevention strategies in the sport. Coaches should be encouraged to emphasize playing the ball along the ground and minimize unnecessary head impact exposures during practice sessions.

Background: People with acquired brain injury (ABI) can experience social isolation and loneliness which can negatively affect their mental health and quality of life. While social media provides a multitude of opportunities for social participation and meaningful connection, its use after an ABI can have increased risk of negative experiences (e.g., trolling, scams). Due to changes in their cognition and communication skills, people with an ABI can also find it challenging to use social media. Rehabilitation clinicians often take a reactive approach to addressing challenges and navigating problematic online communications and currently have limited resources available to assess online communication skills or identify goals for rehabilitation. To address this gap, this study aimed to collaboratively develop a social media and online communication assessment tool to guide and support clinicians and people with brain injury to target social media goals and use during rehabilitation.

Methods: This mixed methods modified Delphi process used focus groups and online surveys, and was co-designed with a large interdisciplinary team, inclusive of people with an ABI.

Results: Twenty-two stakeholders (professionals working with people with ABI n=13, people with ABI n=8, and friends or family of a person with ABI n=1) participated by sharing their perspectives on the content and format that should be included in a social media assessment tool during seven focus groups and via email. Content analysis of focus group and email response data was used to develop the first iteration of the social media assessment tool. Content was grouped into five categories of meaning generated in previous research in the field: Support, Knowledge and Experience, Purpose, Caution, and Networks. In terms of format, a mix of rating scales, short-answer questions, and practical tasks were preferred. A Qualtrics survey was used to determine consensus, whereby sixteen stakeholders provided quantitative and qualitative feedback on the content and format of the first iteration of the assessment tool. Ninety-nine percent of the questions achieved >80% consensus. Subsequent iterations have focused on refining the content and format of the assessment tool based on consensus ratings and the qualitative feedback provided. It was anticipated there would be three rounds of surveys in the modified Delphi process, to be concluded in 2024. Our presentation will discuss the iterative process of development, inclusive of presentation of the agreed upon assessment tool items.

Conclusion: This social-ABI-lity assessment tool for social media and online communication skills after ABI is the first of its kind and provides critical evidence-based guidance to enable clinicians to proactively support people during rehabilitation to build their social media skills for communication and social participation. Future implementation studies are planned to determine construct validity and usefulness of the tool in clinical practice.

Background: Intimate partner violence (IPV) related traumatic brain injury (TBI) is understudied, and no standard of care exists in the United States to simultaneously screen and document for the two overlapping conditions in the clinical setting leading to wide heterogeneity in prevalence estimates and care approaches. The objective for this study was to survey clinicians in the emergency, trauma, and rehabilitation clinical settings to determine challenges, facilitators, and recommendations for screening and managing IPV-related TBI.

Method: This study utilized a mixed methods approach using a cross-sectional online survey distributed among licensed clinicians with direct patient care and who were employed in emergency, trauma, and rehabilitation hospital settings in the United States. The survey was distributed via email to national listserv subscribers (Traumatic Brain Injury Model Systems, the Trauma Center Association of America, and the American Congress of Rehabilitation Medicine) and via snowball sampling. The main outcome measures included a 12-item Likert survey to determine clinician beliefs with screening and managing IPV-related TBI and 4 open-ended text questions designed to identify challenges, facilitators and recommendations for screening and managing IPV-related TBI. Descriptive statistics described respondents and Likert scale responses, and an inductive qualitative content analysis was conducted to prepare, organize, and report text data from the open-ended questions.

Results: Respondents (n=60) were 42.8 ± 10.9 years old, White (83%), Non-Hispanic (93%), female (73%), and primarily physicians (38%) or nurses (42%) within the emergency (52%), trauma (52%), and rehabilitation (30%) settings. The majority (73%) agreed that IPV-related TBI was difficult to diagnose, disagreed that family members accurately relayed cause of injury (77%), disagreed they received training/education on identification (63%) or treatment (67%) approaches, and were not aware of organizational (53%) or state/federal policies (48%) for the overlapping conditions. Content analysis of the open-ended questions generated three primary themes: “Education and Training,” “Clinical Practice,” and “Policies and Resources.” Clinicians lacked education and awareness of IPV-related TBI (e.g., knowledge of injuries, policies, or resources), identified challenges with identification and treatment (e.g., time constraints, lack of clinical experience, ensuring safety, and patients’ hesitancy to disclose circumstances surrounding their injury), noted limited to no organizational, state, or federal policies to guide screening, documentation, and treatment, and described variability in resources to give to patients.

Conclusions: Standardizing education and training across clinical disciplines and specialties may improve the uptake of routine care practices and the accuracy of prevalence estimates which could ultimately justify resource allocation. Future research is warranted to clarify stakeholders’ perceptions using interviewing techniques and to determine the root causes of challenges to identify systematic solutions to this multifaceted problem.

Introduction: Intimate partner violence (IPV) is a major public health concern that affects approximately one in three women in their lifetimes. Physical IPV can involve injuries to the head, neck, or face, leading to a high risk of head trauma (IPV-HT) and probable brain injury (BI). Compared to other forms of HT, IPV-HT presents as a unique phenotype because the mechanisms of injury (i.e., non-fatal strangulation, blunt force trauma, violent shaking, co-occurring mechanisms) are uncommon in other etiologies. More research unmasking the myriad of effects of IPV-HT is urgently needed. However, individuals with IPV-HT represent a vulnerable population with specific needs that must be considered when conducting this type of research.

Methods: Our team is conducting a US-based multi-site study characterizing the cognitive, psychological, and neural outcomes associated with IPV-HT among cisgender women. Thus far, we have completed assessments in 110 women. Study team members identified 5 unique methodological considerations and challenges encountered while working with this population.

Results: 1) Balancing Recruitment Goals with Participant Safety. Approximately 45% of participants were excluded or were not contacted for scheduling due to safety concerns (e.g., experiencing current IPV). 2) Training in Trust and Transparency. Working with IPV survivors requires extensive training. Researchers must build trust and be transparent about research requirements and potential impact. A comprehensive description of the research procedures/expectations is needed, particularly for survivors who may feel betrayal from individuals they trusted and were responsible for their traumas. 3) Research Procedures Invoking Emotional Reactions. Neuroimaging can provide a wealth of injury-specific information. However, its use must be balanced with survivor comfort. A small proportion of our participants experienced heightened reactions to the environment/machine (e.g., banging noise, closed space). 4) Maintaining Standardized Protocols while Validating Participants. BI screening instruments and neuropsychological assessments require standardized administration. However, some flexibility is needed for this trauma-exposed population. It is helpful to provide additional encouragement and empathy, without invalidating results, to minimize the effects of posttraumatic stress disorder (PTSD) symptoms, such as negative feelings about self. 5) Lack of IPV-HT Specific Research Tools. Many of the assessments used in IPV-HT research were developed for BI sustained outside of the unique context of IPV and limited work has been done on the psychometric validation in this population. Incorporation of survivors, participants, and IPV-HT researchers' experiences is needed to accurately characterize how the combination of IPV, PTSD, and BI uniquely affects outcomes among those with IPV-HT.

Conclusion: Working with IPV survivors requires a unique trauma-informed approach. We provide lessons learned from our team to help others design and implement studies to ensure that their research objectives are obtainable while balancing participant needs.

Even though COVID-19 is primarily a respiratory illness, it can affect more than 10 physiological systems, with over 200 reported symptoms. Around 30% of individuals infected with COVID-19 experience symptoms persisting beyond 12 weeks post-infection, known as Post COVID-19 condition (PCC). The 3 main symptoms of PCC 6 months post-infection include fatigue, brain fog, and post-exertional malaise. PCC has been associated with changes in the blood-brain barrier, grey matter loss, and decreased brain excitability. These brain changes may underlie the residual and persisting symptomatology of PCC.
This study aimed to identify the electrophysiological correlates associated with the main lingering symptoms of PCC. We used electroencephalography (EEG) data captured with a 64-channel cap (Brain Products, Germany) to explore the changes in brain oscillatory and functional properties during rest and hand movements in 20 PCC participants (43±10 yo; 14 females; 24±11 months post-infection) and age- and sex-matched controls. Mean post-movement beta rebound (PMBR), measured as percent change in beta power relative to baseline, was found to be significantly lower in the PCC group (3.8% ± 18.1%) over the sensorimotor area (electrode C3, p= 0.039) compared to the control group (18.5% ± 21.7%), as determined by an independent samples t-test. Additionally, the aperiodic exponent of the power spectral density measured at rest was significantly elevated in PCC within slow frequencies (2-7 Hz), specifically at the parietal lobe electrodes Pz (p= 0.011) and CPz (p= 0.034). The mean values for the Pz electrode were = 0.85 ± .5 for the PCC and 0.46 ± 0.35, for the control group, while for CPz, they were 0.89 ± .054 for the PCC and 0.53 ± 0.3 for the control group, also determined by independent sample t-tests. Pearson correlation analyses showed that higher PMBR values were associated with lower Cognitive Failure Questionnaire scores (r= -0.36, p= .03). Additionally, aperiodic exponents were associated with fatigue severity scale (FSS) (r= 0.41, p= 0.013). Reduced PMBRs observed in PCC suggest impaired sensorimotor control, affecting motor inhibition and learning. Elevated aperiodic exponents over the parietal and central regions suggest increased neuronal inhibition in sensory and motor processing areas. The associations between specific EEG features and clinical scores underscore their value as potential biomarkers for the symptomatology present in PCC.
These results represent a critical step toward developing diagnostic methods and targeted treatments to alleviate the debilitating symptoms experienced by this population.

The purpose of this study was to examine the impact of an interoception-based intervention on self-regulation and executive functioning in adults who have sustained mTBIs, specifically concussions. Self-regulation and executive functioning are two skills that are impacted after one sustains a mild traumatic brain injury (mTBI). Interoception, one of our body’s 8 senses, is the ability to recognize and perceive physiological body signals such as hunger, pain or fatigue. This poster aims to educate professionals and survivors about the positive effects of an interoception-based intervention on adults with mTBIs. While research suggests that improving interoceptive awareness can have a beneficial effect on self-regulation skills, there is a lack of research exploring its connection to mTBIs and a shortage of studies investigating its wider implications. This poster explores the intricate relationship between TBIs and interoception and why interoceptive awareness is impacted. The study used a one-group pre- and posttest design and implemented materials from the course “Concussion, Traumatic Brain Injury, and Interoception” by Dr. Meghan Chemidlin and Dr. Kelly Mahler. The study included nine participants (eight females, one male) aged 25 to 75. Two assessments, the Behavior Rating Inventory of Executive Function- Adult Version (BRIEF-A) and the Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2), were used to measure self-regulation and executive functioning. Both assessments showed statistically significant changes between the pre-intervention and post-intervention scores for self-regulation and executive functioning. This was the first study to examine the impact of materials from the course ‘Concussion, Traumatic Brain Injury and Interoception’ on individuals with mTBIs. The results indicated that a 6-week interoception-based intervention effectively improves self-regulation and executive functioning skills in individuals diagnosed with mTBIs.

Visual impairment is a commonly observed symptom in patients with acquired brain injury (ABI), often affecting their physical, cognitive, and communication functioning. Timely identification and accurate diagnosis of these issues are crucial for effective management, ultimately improving rehabilitation outcomes. This study aims to summarize the various causes of visual deficits in ABI patients, as some may be overlooked by clinicians. Here we present 6 types of clinical conditions including: (1) Visual field deficits resulting from damage to the visual pathway due to ABI, with the specific areas of vision loss depending on the location of the injury along the pathway; (2) Visual neglect or visual inattention, usually occurring after damage to the right hemisphere of the brain, which affects the ability to perceive objects or events on the left side of space; (3) Terson syndrome, a rare condition characterized by vitreous hemorrhage associated with subarachnoid hemorrhage, often due to an aneurysm rupture. The condition is a result of increased pressure in the brain, which in turn can lead to leakage of blood into the eyes; (4) Eye injury resulting from blunt trauma in patients with traumatic brain injury, leading to complications such as intraocular bleeding and retinal detachment, both of which may cause vision loss. Additionally, injuries to the orbit and surrounding soft tissue can result in misalignment of the eyeballs, leading to double vision (diplopia); (5) Injury to the cranial nerves 3, 4, and/or 6 causing diplopia resulting from different types of ABI; (6) Undiagnosed pre-existing eye conditions, such as amblyopia, strabismus, macular scarring, etc. We are a multidisciplinary team specializing in adult ABI rehabilitation. For patients with visual impairments, we closely monitor their recovery and offer compensatory strategies to address their visual deficits. Effectively managing visual impairment is crucial to achieving optimal functional outcomes in their ABI rehabilitation.

Objective: Recent research suggests that clinical recovery from concussion may not align with longer physiological recovery, and a history of concussions can affect outcomes of subsequent injuries. Our study aimed to examine how concussion history influences performance on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), heart rate variability (HRV), resting-state quantitative electroencephalography (rs-QEEG), as well as post-concussion symptoms and psychological health indicators, at baseline and following a recent concussion.

Methods: Data was prospectively collected within a pre-existing concussion management program. Preseason baseline included psychological health questionnaires and the ImPACT, which includes a post-concussion symptoms scale. HRV and rs-QEEG evaluations were mandatory for high-risk sports athletes (football and basketball) and optional for others (volleyball and flag football). A total of 169 athletes (55 females) aged 16-22 completed baseline testing. Among them, 96 reported no prior concussion, 54 reported at least one, and 18 reported two or more. During the season, 30 concussion cases (8 females) were followed, of which 19 had no history of concussion, 11 had at least one prior concussion and 7 had two or more. Post-concussion assessments were conducted within 72 hours.

Results: At baseline, compared to athletes with no previous concussion, those with one or more prior concussions reported higher Vestibular-Somatic symptoms (p = 0.003, Cohen’s d = -0.639), and those with two or more prior concussions displayed higher scores on the Beck Depression Inventory-II (p = 0.004, Cohen’s d = -0.732) as well as elevated Cognitive-Sensory (p = 0.001, Cohen’s d = -0.832), Vestibular-Somatic (p = 0.003, Cohen’s d = -0.762), Affective (p = 0.006, Cohen’s d = -0.705), and Total Symptoms scores (p = 0.004, Cohen’s d = -0.739). No significant differences were found for Beck Anxiety Inventory, ImPACT Index Scores (Verbal and Visual Memory, Impulse Control, Visual Motor, Reaction Time), HRV or rs-QEEG values. Following a new concussion, the HRV measure RMSSD (root mean square of successive differences between normal heart beats) in standing position differed between groups, where athletes with at least one prior concussion showed lower RMSSD than those without (p = 0.001, Cohen’s d = 1.236).

Discussion: Athletes with a history of concussions report more Vestibular-Somatic symptoms, suggesting they may persist longer and remain under-treated. Additionally, our study adds to the evidence for an association between a history of concussions and depressive symptoms. Even when deemed recovered, athletes with a history of multiple concussions continue to exhibit greater overall post-concussive symptoms. Finally, although the literature on this topic is sparse, both our findings and existing studies point to concussion history being associated with lower HRV RMSSD, which could reflect dysautonomia. These results add to our understanding of the physiological impacts of repeated concussions and should be considered during clinical management.

I vividly remember the struggle of trying to find normalcy in a situation that defied it. Receiving a call from the hospital about my husband's bike accident was a “no turning back” moment in time.

I relied on my curiosity and research skills to find the right help for my husband's recovery. Embracing ambiguity became my norm as I sought answers and connected with various
practitioners.

Using the same skills that helped my husband, I employ those same skills to Stand up 4 ME. Now helping other caregivers using my 4-step Stand up 4 ME Framework.

This 4-step framework:

1) FINDING THE STRENGTH WITHIN
Discovering the depth of one’s internal strengths which often exceeds one’s awareness. Harnessing these innate abilities to confront life's trials.

2) LAYING THE GROUNDWORK
Filling one’s Resource toolbox with essential tools for the journey, including networking, thorough research, and connecting with individuals with lived experience. Together, these tools build the foundation for navigating one’s journey.

3) NAVIGATING SYSTEMS
Bravely step out, advocate for oneself and those one supports and push the boundaries to ensure all needs are met and voices are heard.

4) ENERGY MANAGEMENT
Unlock the power within to become one’s lifesaver - prioritize one’s physical, mental, and emotional well-being. Embrace practices that nourish and sustain one’s energy.

Twenty-seven years later, the journey continues. The front-line, caregiving spouse is still an integral resource for assisting one’s spouse, helping to create a safe and secure environment for continuous improvement, and keeping the home running on all cylinders.

Objective: In 2020, firearm injury became the leading cause of death among children and adolescents in the United States (US). Firearm injuries to the head have an especially high mortality rate, yet more research is needed to understand the demographics, injury characteristics, and outcomes of the patients that survive their injuries. We performed a retrospective chart review on pediatric patients who survived a firearm injury to the head in a large US city.

Design: We included patients aged 0 to 17 who presented for a firearm injury to the head at any Level 1 trauma center in Houston, Texas from January 2018 to December 2020, and survived to hospital discharge. Patient demographics and data on the initial injury were abstracted from the National Trauma Data Bank (NTDB). Trauma center electronic medical records were used to abstract any information not obtained from the NTDB, including injury-related symptoms documented in follow-up visits 3 months or later from the initial injury.

Results: There were 22 pediatric patients with head injuries from firearms included in our review, of which 18 were male. Median age was 16 years (interquartile range [IQR] 2.5 years). There were 7 Black patients, 10 Hispanic patients, and 4 White Non-Hispanic patients. The most common shooting context was assault (11 instances), followed by unintentional (5 instances). Eighteen patients were admitted to the Intensive Care Unit and 16 were intubated. Median length of acute care stay was 6.5 days (IQR 8 days). Eleven patients were discharged home, and 9 patients were discharged to inpatient rehabilitation. Out of 20 patients who had follow-up visits at 3 months or later, 11 patients had at least one residual symptom.

Conclusions: Pediatric firearm injuries to the head are an infrequent but devastating event. Half of the patients in our study had residual symptoms, such as mobility deficits, persisting three months after their injury. This may result in chronic disability and affect quality of life. Therefore, follow-up and early referral to rehabilitation services is important for pediatric survivors of firearm injury.

Episodic memory is one of the most frequently impaired cognitive functions in patients assessed in neuropsychology. Among the causes, traumatic brain injury (TBI) is one of the many pathologies which can impair episodic memory. More specifically, moderate to severe TBI can induce long-term as well as acute memory impairments, the latter being known as post-traumatic amnesia (PTA). This transient state of amnesia is mainly defined as the inability to form new memories (i.e. anterograde amnesia). This common assumption that the patient is incapable of learning delays their entry into rehabilitation, which can be associated with poorer long-term outcomes. However, little is known about the real capacities of the patients to learn new memories, nor which episodic memory processes (encoding, consolidation, retrieval) are specifically impaired during this transient state. Thus, this study aimed to evaluate which processes of visual episodic memory are altered during PTA. Participants recruited in a hospital setting after sustaining a moderate to severe TBI completed a brief battery of tests assessing cognitive functioning as well as visual memory (EXACT). Half of them were in PTA and the other half had emerged. Preliminary results indicate a more significant impairment of the retrieval process for PTA patients as compared with patients who had emerged. No significant differences were found for the encoding and consolidation processes. Acquiring knowledge about the cognitive correlates of PTA could lead to tailored interventions that could be administered earlier to patients, with the aim of improving long-term recovery prognosis. Also, advancing knowledge on PTA will enhance theoretical models of episodic memory functioning, with the goal of improving clinical practices related to the assessment and management of all patients with episodic memory impairment.

There is an emerging field of practice in health research to involve patients in the research that impacts their lives. This process, called Public and Patient Involvement (PPI), is gaining traction. PPI empowers members of the public and those with lived experience to participate and collaborate with researchers. Many funding agencies have PPI as a funding requirement.

ABI researchers are beginning to navigate their way in this PPI world. Patient organisations play a vital role. Acquired Brain Injury Ireland, as a national organisation has been working in multiple ways to engage people with brain injury in ABI research both within our organisational structures and with external research partners. As a new area of work, we are often learning by doing. Researchers are also in the same position. Together we are creating a number of methods for best practice PPI.

Internally, we have invested time and resources to ensure that people with ABI and their families are represented on our research structures. We have two experts by experience on our Research Ethics Committee. We engaged over a hundred people with ABI and their families in our research prioritisation exercise, the largest stakeholder voice in the consultation process. At our annual research conference, an expert by experience is included on the programme. We have facilitated two researchers with lived experience of TBI and stroke to complete their research projects (PhD and MSc.) and achieve publication.

Externally, we are working with several academic institutions. This includes supporting PPI as a core feature of a TBI study in Dublin City University. With seed funding, the Irish Critical Care Clinical Trials Hub in University College Dublin worked with us to develop an ABI PPI panel. We are collaborating with researchers in Trinity College Dublin to recruit PPI representatives for an interdisciplinary TBI research programme. We have a PPI representative on an international TBI outcomes research project in the University of Toronto.

We are capturing learning and identifying the barriers and enablers. The barriers include the limited knowledge and know-how and the lack of resources to support people with ABI and their families to participate (for e.g. funding for travel, stipends and accessibility requirements). There are several enablers to this work including ethical recruitment and retention, meaningful engagement, balancing expectations and ambitions, making the process accessible and ensuring equitable communications.

People with ABI have a limited voice in ABI research discourse. Our experience of PPI to date illustrates its value and potential. There is work to be done to make it systematic, sustainable and embedded in research practice requiring commitment from all stakeholders. The landscape of ABI research will have to be open, flexible and willing to change the power dynamics.

Background: Adolescent sport-related concussion (SRC) is a serious public health problem in contact sports. In general, systematic reporting is not required, reflected by limited infrastructure and support for reporting. Major gaps exist in understanding adolescent SRC epidemiology. Regional and nationwide monitoring programs are of interest, but financial and practical aspects are not well understood.

Methods: Local, regional, and state-wide high school SRC monitoring programs and nationwide research were identified to determine cost and other practical aspects, and potential barriers to implementation. Resources included 1) State Education department websites, 2) Compiled lists of state-level laws and implemented programs (through Centers for Disease Control and Prevention as well as the Brain Injury Association of New York State), and 3) programs highlighted through professional networks. Costs were determined through 1) the above, 2) projections of athlete volume in The National Federation of State High School Associations, and 3) publicly available program- and state-level fiscal end-of-year program financial documents. Cost estimates included physicians, data managers, systems fees, and educational resources. Athletic trainer support varied across models. State- and athlete- level costs modeled a program in New York with 341,454 athletes.

Results: Publicly available data were reviewed, and semi-structured interviews were conducted with program coordinators at regional (a rural New York high school district), state (Hawaii Concussion Awareness Management Program (HCAMP) and North Texas Concussion Registry (ConTex) programs) and national (High School Reporting Information Online (RIO)) levels. Infrastructure varied from volunteer-based to state-funded mandatory programs. Support ranged from state support enhanced by traffic violation surcharges to philanthropic or volunteer resources. State-level cost estimates for New York State ranged from $677,635.2 to $37.7M, with per athlete costs of $1.98 (national model) to $110.54 (local model). Logistic challenges, including medical personnel and data infrastructure, appeared manageable at scale in each model.

Conclusion: High school SRC monitoring programs are feasible and often cheaper than routine costs associated with sports participation (e.g. uniforms and standard equipment). These models provide guidance for possible implementation of state- and federal-level programs. Large, inclusive programs are necessary to identify critically understudied aspects of SRC including health disparities as relates to SRC detection, reporting, and recovery in diverse populations.

Background: Following a severe brain injury, patients in a disorder of consciousness (DoC) have few treatment options. Zolpidem, a GABAergic agonist prescribed for insomnia, paradoxically induces arousal in some individuals. However, propofol, another GABAergic agonist and one of the most administered drugs in critical care, remains underexplored for this purpose. Given that neural complexity is hypothesized to be a necessary feature for the emergence of consciousness, we aimed to uncover potential therapeutic effects of propofol through changes in Approximate Entropy (ApEn), a measure of signal complexity, following brief propofol sedation. As a measure of signal complexity, ApEn serves as an indicator of the brain's ability to operate optimally.

Methods: We recruited 17 non-sedated patients (49.1 ± 19.4 years; 9 females) in a coma (n = 3), unresponsive wakefulness syndrome (UWS) (n = 13), or minimally conscious state (MCS) (n = 1) following a brain injury (median Coma Recovery Scale-Revised (CRS-R) score of 4.4 ± 2.9). Propofol was administered using a target-controlled infusion pump at a concentration of 2.0µg/ml and maintained for 13.7 ± 9.7 minutes. Resting state 128-channel EEG was recorded before and after the sedation period, once the concentration fell below 0.05µg/ml. The recordings underwent preprocessing using MNE Python, involving downsampling to 250 Hz and bandpass filtering (0.1-50 Hz). Non-scalp and noisy channels were removed, and the data were segmented into non-overlapping 10-second epochs. Epochs with excessive artifacts were then removed. ApEn was calculated over non-overlapping 10-second windows, then averaged over the whole signal for each electrode using code from the AntroPy toolbox. Intra-subject analysis involved comparing electrode pairs before and after propofol using paired samples Student’s t-tests or Wilcoxon signed-rank tests, depending on the fulfillment of the normality assumption. Pearson’s correlations were used to investigate the association between ApEN changes and other factors such as time since injury and etiology, and sedation duration.

Results: On a group level, ApEn was 0.458 ± 0.224 before and 0.471 ± 0.226 after propofol exposure (p > 0.05). On a single-subject level, 9 (53%) of the 17 patients had an increase in ApEn, 4 (23.5%) showed a decrease and 4 (23.5%) showed no variation. Sedation duration, time since injury and CRS-R score were not associated with ApEn , nor was brain injury etiology or current diagnostic category (e.g., coma, UWS, MCS) (all p-values > 0.05).

Conclusions: The observed increase in ApEn following propofol sedation in a majority of patients suggests the drug's potential to enhance complexity and functional integration in the DOC brain, aligning with zolpidem’s paradoxical arousing effects noted in some individuals. This study suggests the presence of a patient-specific heterogenous effect of propofol on the DOC brain, highlighting the need for the development of personalized medicine in this field.

Background: Risk management of concussive blows to the head continues to be a challenge during several occupational and sports activities. Recent evidence suggests cervical muscle activation is enhanced if the lower jaw is optimized in its physiologic resting position (Streifer 2019; Garret 2023). In addition, the odds of sustaining a concussion have been shown to be 84% higher in females than in their male peers. Therefore, it is surprising that there is only limited research available to address gender responses to proper jaw alignment and concussion risk (Koerte 2020).

Purpose: Investigate cervical muscle strength and endurance response to optimal positioning of mandibular interocclusal appliance based on gender.

Methods: 42 healthy participants (20 females/22 males) ages >18 years old, were sampled by convenience. Inclusion criteria: normal cervical spine AROM, no recent head or neck trauma or surgery. Exclusion criteria: active cervical pain and any cervical spine postural abnormalities. Participants were first screened by a physical therapy orthopedic specialist to ensure normal range of motion. Then all participants were examined and custom-fitted with an interocclusal mouth appliance (IMA) to ensure optimal mandible positioning by a neuromuscular dentist. A clinical, digital pressure gauge and stop watch were used to assess neck directional strength (kg-force) and endurance (sec): 1. Flexion-strength, 2. Extension-strength, 3a. Right Side-Flexion, 3b. Left Side-Flexion, 4a. Right Side-Rotation, 4b. Left Side-Rotation, 5. Flexion-endurance, 6. Extension-endurance. Participants were tested without and then with IMA in place.

Data Analysis: SPSS was used for descriptive statistics, paired T-Tests and 2-way repeated measures ANOVA to explore differences at alpha = 0.05 with a Greenhouse-Geisser correction factor and Wilk’s Lambda to test multivariate sample effects and observed power.

Results: There were 42 participants (F/M = 20/22). Average age = 26.8 (8.9) and BMI = 22.09 (9.67). There were significant differences were found in strength and endurance based on IMA Condition, (F₁,₄₀) = 7.263, p < 0.001, ηp²= .154) and Muscle Direction, (F₅,₃₆) = 72.015, p < 0.001, ηp²= .643). However, there were no significant differences due to Gender, (F₁,₄₀) = .146, p = .710, ηp²= .003).

Conclusions: Project results suggest significant immediate, increased neck strength and endurance responses with a customized IMA for optimized positioning compared to baseline or no appliance use. Females were overall significantly weaker than males which was not surprising. However, results did indicate both genders responded proportionately in similar to males with enhanced muscle response to conditions.

Clinical Relevance: Suggested immediate gains in cervical spine strength and endurance may assist concussion risk management for contact sports at all levels and for both genders. Results also suggest the need for further research about how proper jaw alignment might optimize neck muscle response over a broad spectrum of applications including training and competitive activities.

The vast majority of concussion research is sampled from a small subset of society: emergency department and specialty care visitors, adolescents, college athletes, and military service members––most of whom are not disabled. The populations sampled in the literature base are broadening, but many communities are still underserved. This gap in research contributes to the lack of literature, resources, and support for individuals with a pre-existing disability navigating concussion recovery. To address this gap, Concussion Alliance has created a first-of-its-kind, online patient-facing resource for this population.

The Concussion in Para Sport (CIPS) Group produced its first position statement in 2021 to begin addressing this gap in resources for clinicians serving para-athletes and the “paucity of concussion research related to para-sport” (Weiler R. et al., 2021). However, athletes with disabilities represent a small portion of a larger population of disabled patients in need of more research, resources, and support. According to the CDC Disability and Health Data System, 28.7% of adults in the United States live with some type of disability (Centers for Disease Control and Prevention, July 2024); 12.2% of adults have a mobility-related disability, 6.2% have a hearing-related disability, and 5.5% have a vision-related disability. The World Health Organization reports that 16% of the world’s population lives with “significant disability.”

Evidence shows that injury presentation, assessment, and treatment practices are more complex for para-athletes and are often not easily translatable between athletes and para-athletes (Weiler R. et al., 2021). Further, a significant minority of concussion patients experience symptoms that persist beyond the four-week recovery timeline outlined by the 6th Consensus Statement on Concussion in Sport (Patricios JS et al., 2022). Given that timely and appropriate assessment, treatment, and referral for rehabilitative care are critical in mitigating persisting symptoms, concussion patients with pre-existing disabilities may be at greater risk for poor outcomes.

To address this information gap, Concussion Alliance’s resource, “Individuals with a Pre-Existing Disability,” includes unique resources to support concussion patients navigating the complex interaction of concussion recovery and their disability. The resource (created with CIPS Group Co-Chair Dr. Osman Ahmed and disability advocates) presents a novel first step toward community-specific concussion resources for individuals with disabilities––athletes and non-athletes alike. The resource includes sections on identifying and treating concussions, persisting symptoms, mental health, disability stigma, and navigating healthcare, and a subsection for blind and visually impaired individuals.

The current iteration of the resource focuses on vision impairment, an area in need of urgent measures (Teodoro et al., 2024), but it is constructed to be broadly applicable to individuals with other disabilities. Concussion Alliance, Dr. Ahmed, and disabled advocates plan to continue to expand these resources in the future to include evidence-based, condition-specific resources for other disabilities.

Background: Until very recently, the intersection of intimate partner violence (IPV) and brain injury (BI) has been almost entirely overlooked in research, practice, and policy, despite the known risks associated with the two conditions. Globally, one in three women will experience IPV in their lifetime. Physical violence during IPV can cause neurological deficits, loss of consciousness, and BIs, both through blows to the face, head, and neck, and through non-fatal strangulation. Individually, BI and IPV are associated with elevated rates of unemployment, poverty, and homelessness, as well as increased risk of mental health challenges and addictions. A general lack of IPV-BI awareness, gaps in screening, and unique barriers to healthcare and social service provision leave many survivors undiagnosed and/or unaware of their BI, further complicating identification and support. Additional complications are embedded in professional siloing and a lack of interdisciplinary cross-pollination, misdiagnosis, and the lack of IPV-BI sensitive services. To date, there has been limited research identifying barriers and facilitators to IPV-BI support, and very few available practice resources, despite an identified need. The researchers here have been working to address this gap and will report on the current state of knowledge, while sharing support resources developed through community-based projects.

Methods: A number of research projects have been undertaken with the goal of producing IPV-BI education and practice resources. Researchers employed qualitative, community-based, participatory methods, and conducted surveys, semi-structured interviews, and focus groups to gather data. These projects explored: (a) service providers knowledge and awareness of IPV-BI, and how to recognize and respond, (b) survivors’ and service providers’ experiences of IPV-BI services; (c) perceived support needs; (d) existing programs, policies, and practices; and (e) valued characteristics of healthcare and social support services. Participants were recruited from a national informal IPV-BI network, through local, regional, and national women’s shelter and brain injury support organizations, or through snowball sampling. University of Toronto, University of British Columbia-Okanagan, and Wilfrid Laurier University Research Ethics Boards granted ethical approvals.

Findings: Researchers used a qualitative, thematic analysis approach, attached descriptive codes, and then grouped findings into broad, topic-oriented categories and identified recommendations for practice resources. Applying a knowledge to action framework, the results were then used to develop multiple resources to support frontline workers and healthcare providers that are freely available via Supporting Survivors of Abuse and Brain Injury through Research (SOAR; www.soarproject.ca) and the Abused and Brain Injured Toolkit (www.abitoolkit.ca).

Conclusion: These projects address critical gaps in understanding the impact of IPV-BI and the resources available to support social service workers and healthcare providers. Many of these resources are the first of their kind globally, and provide practical solutions to better support women exposed to IPV-BI.

Background: The Patrol Exertion Task (PET) is a subtask within the Complex Assessment of Military Performance (CAMP) test battery. The task was designed for multitask assessment, and active duty servicemembers (ADSM) are instructed to monitor a simulated foot patrol on a screen while holding an instrumented weapon that makes audible signals at pre-programmed times. The auditory signals serve as cues for reaction time (RT) responses, which are collected by pressing a button on the instrumented weapon. The task is completed under conditions of sustained exertion where the ADSM is asked to continuously step onto a 12-inch stool throughout the duration of the 10-minute task. Additional elements that are collected during the task include heart rate, rate of perceived exertion, and other cognitive components that require the ADSM to identify and recall specific elements that are located throughout the simulated patrol.

Methods: The purpose of this study is to compare performance on the PET between ADSM who are seeking treatment for persistent mTBI symptoms with a peer group of ADSM who may have a history of mTBI but are relatively symptom free and have not had a mTBI within the past 2 years. 57 ADSM (average age: 27.6 ± 6.4 years) were recruited for the healthy control (HC) group and 60 ADSM (average age: 30.9 ± 7.3 years) were recruited for the mTBI group.

Results: The overall average for the 12 RTs collected throughout the simulated foot patrol was 419.0 ± 86.1ms for the HC group, and 455.0 ± 144.5ms for the mTBI group, but the overall RT average was not statistically significant (t = -1.6312, df = 97.076, p-value = 0.1061, 95%CI = [-79.75, 7.80]). When the RTs were binned into quarters (3 RTs per bin), there was an overall trend of RT improvement throughout the task (HC: 1st quarter = 457.1ms, 2nd = 447.7ms, 3rd = 382.9ms, 4th = 392.2ms) (mTBI: 1st = 510.9ms, 2nd = 467.5ms, 3rd = 424.0ms, 4th = 415.1ms ) but only one group showed statistical significance (1st quarter: t = 1.9441, df =101.33, p-value = 0.05, 95%CI = [-108.76, 1.09]).

Conclusions: The PET was designed to test ADSM ability to multitask under exertional conditions, and they are asked to balance multiple cognitive and motor tasks simultaneously. The reaction time data alone suggest that the mTBI group initially struggles to engage with the RT component of the task, but quickly develop a strategy to complete the task that is comparable to the HC group. Analysis of the additional cognitive components of the PET will be completed to further contextualize the RT results.

Background: The Complex Assessment of Military Performance (CAMP) is a test battery that was designed to closely reflect the occupational demands of active duty servicemembers (ADSM). The test battery includes 3 subtasks of increasing complexity, with the Patrol Exertion Task (PET) administered last. The PET was developed with military collaborators to incorporate high level skills that all ADSM must be able to perform, including reacting quickly, maintaining visual stability during dynamic movements, and identifying operationally relevant information under sustained physical exertion.

Methods: 33 (average age: 27.7 ± 5.7 years) ADSM without a mTBI within the past 2 years and are relatively symptom free completed the PET during two different test sessions that were at least 4 weeks apart. Throughout the PET, the ADSM was instructed to monitor a simulated foot patrol for signs of enemy presence while continuously stepping onto a 12-inch stool. During the task, the ADSM was also instructed to respond to an auditory stimulus by pressing a button on a simulated weapon as quickly as possible to measure reaction time (RT). 12 RTs were recorded throughout the 10-minute simulation.

Results: The overall average for the 12 RTs collected throughout the simulated foot patrol was 402.2 ± 70.7ms for the first test session, and 378.8 ± 76.2ms for the second test session. The test-retest reliability was found to be moderate (ICC=0.73, p<.001, 95%CI= [0.66, 0.78]). The average for the first 6 RTs was 435.3 ± 94.3ms for the first test session, and 384.5 ± 86.2ms for the second test session. The test-retest reliability for the first half of the RTs was found to be moderate (ICC=0.62, p<.001, 95%CI= [0.49, 0.70]). The average for the last 6 RTs was 369.2 ±62.2ms for the first test session, and 373.0 ± 73.3ms for the second test session. The test-retest reliability for the last half of the RTs was found to be moderate (ICC=0.63, p<.001, 95%CI= [0.55, 0.69]).

Conclusions: The PET was designed to present a multitask challenge that is complex enough to approximate real-time challenges that ADSM face during active duty. While there is moderate test-retest reliability for the 3 RT components of the task, further analysis is required to quantify RT performance in relation to the other cognitive tasks that are also present.

Background: The Complex Assessment of Military Performance (CAMP) test was designed for use by physical therapists to aid in return-to-duty recommendations. The purpose of this observational study is to evaluate performance on components of the CAMP test battery for ecological validity and to improve outcome measure development. The Patrol Exertion Task (PET) is a subtask within CAMP that was designed for multitask assessment, and active duty servicemembers (ADSM) were instructed to complete cognitive and motor tasks while watching a 10-minute simulated foot patrol. Throughout the simulation, an instrumented weapon is used to collect reaction time (RT) performance by recording the time it takes for the ADSM to push a switch after hearing a pre-programmed auditory cue.

Methods: 31 ADSM (average age: 33.0 ± 6.7 years) who have sustained a mTBI within the past 2 years and were seeking treatment for persistent symptoms were recruited for the study. Pre- and post-intervention data were captured via the PET to quantify changes in performance after completion of a prescribed intervention. 12 RTs were recorded throughout a simulated foot patrol with a sustained exertion task of continuously stepping onto a 12-inch stool.

Results: The overall average for the 12 RTs collected throughout the simulated foot patrol was 437.3 ± 114.4ms for the first test session, and 392.0 ± 71.8ms for the second test session, and the pre-post improvement in RT was statistically significant (t = 2.597, df = 30, p-value = 0.014, 95%CI = [9.65, 80.83], mean differences between pairs = 45.25). The average for the first 6 RTs collected was 476.4 ± 110.5ms for the first test session, and 398.3 ± 73.5ms for the second test session, and the pre-post improvement was statistically significant (t = 4.648, df = 30, p-value = 6.28e-05, 95%CI = [43.78, 112.41], mean differences between pairs = 78.09). The average for the last 6 RTs collected was 392.9 ± 126.0ms for the first test session, and 387.6 ± 79.3ms for the second test session, but the pre-post change was not significantly significant (t = -0.3486, df = 28, p-value = 0.7226, 95%CI = [-41.57, 29.18], mean differences between pairs = -6.19).

Conclusions: There was statistically significant improvement in RT for the full PET and the first 6 RTs, however the improvements for the last 6 RTs were minimal. The PET was designed to test ADSM ability to multitask under conditions of exertion, so the variation in RT performance throughout the task may suggest that there are lingering post-mTBI effects that are difficult to identify from single-task assessment alone.

Background: There is high quality and evolving evidence for implementation of high intensity gait training (HIT) for recovery and optimization of ambulatory function in the neurologic patient population. Clinical Practice Guidelines in physical therapy presented recommendations for implementation of HIT for individuals following brain injury based on high levels of quality research in stroke and the common pathways to neuroplastic recovery shared amongst the populations. This study utilized a quasi-experimental retrospective analysis of therapeutic interventions and mobility outcomes for individuals following an acute stroke or BI who received PT services during inpatient rehabilitation from October 2021 to September 2022. Only recently has HIT focused on walking tasks been assessed in individuals with BI, and only in a chronic (> 6 months) ambulatory population, and the present data provides some insight into the utility of HIT in more impaired individuals early following BI.

Methods: During a 1-year quality-improvement initiative, therapists in a rehabilitation facility chose to provide HIT or traditional strategies to individuals with BI, with documentation of which interventions were utilized. Documented training records for each patient determined whether an individual received HIT or traditional interventions. Criteria for assignment to the HIT group included an attempt to reach ≥ 75% age-predicted HRmax, (age-predicted HRmax =208-0.7*age22) or ratings of perceived exertion (RPE) of ≥ 15 (i.e., “hard”; range: 6-20)23 while performing walking training activities. In patients prescribed beta-blockers, targeted HR ranges were reduced by 10 beats/min.

Results: Outcomes were collected at admission and discharge to delineate patterns of recovery. In individuals early BI, changes in 10-m walk test (10MWT) and Berg Balance Scale (BBS) were retrospectively compared over 1-year with physical therapists (PT) selecting to provide HIT ( BI=57) or traditional interventions ( BI=60). Individuals post BI receiving HIT achieved 3 to 4-fold greater gains in primary outcomes of 10MWT and BBS than individuals receiving traditional interventions (both p<0.01). For QI-mobility scores, while between-group comparisons of changes were significant (p<0.05) demonstrating that the HIT group demonstrated greater independence with all functional mobility including ambulation and stair negotiation. However, differences in demographics and baseline assessments suggest those who were younger received HIT (p<0.01).

Limitations: A limitation of the present study was the use of a quasi-experimental design with unblinded assessors also delivering the interventions, consistent with routine physical therapy. An additional related limitation was the lack of randomization, which introduced selection bias of individuals to perform HIT or traditional interventions.

Conclusions: In this retrospective analysis of a quality-improvement project, attempts to prioritize walking training and achieve higher cardiovascular intensities during inpatient BI rehabilitation may have led to significant improvements in mobility outcomes. The bias observed in the data, while often assumed, may inform future implementation strategies.

Introduction: In neurosurgical ICUs, external ventriculostomy drain (EVD) transducers are zeroed using one of two methods: an "open" method, which requires removal of the non-vented cap from the transducer or a "closed" method which involves lowering the buretrol to zero. While the closed method has the advantage of maintaining a closed, sterile system, it goes against manufacturer guidelines and may compromise accuracy.

Objective: To directly compare the accuracy of each zeroing method and to assess whether any differences in accuracy are consistent across different brands of EVD collection systems.

Methods: This was a blinded, prospective bench study. An EVD collection system (Integra or Natus brand) was connected to a saline bag. The height of the saline bag was changed to generate pressures from 5-30 mmHg which were confirmed by a manometer connected in series (ground truth). One examiner zeroed the transducer (Edwards Lifesciences TruWave Arterial Line Transducer) using one of the methods dictated by a random number generator. Another examiner, blinded to both the zeroing method and manometer level, then recorded the pressure from the monitor. Paired T-tests then compared the accuracies of each zeroing method and each EVD brand.

Results: 612 data points were collected across two brands of EVD collecting systems paired with separate Edwards Lifesciences brand transducers. Mean differences from ground truth for all open and closed method trials, including both brands, were 0.66 and 0.31 mmHg respectively (p<0.0001). Successful trials, defined as accurate within 1 mmHg of ground truth, were 88% and 99% respectively. Additionally, mean differences from ground truth between open and closed method trials using the Integra brand collecting system (n=408) were 0.55 and 0.29 mmHg (p<0.0001) with success rates of 85.5% and 99% respectively while mean differences from ground truth between open and closed method trials using the Natus brand collecting system (n=204) were 0.86 and 0.35 mmHg (p<0.0001) with success rates of 94% and 99% respectively.

Conclusions: While the transducer manufacturer recommends opening the cap for zeroing, here we demonstrate that (1) EVD systems can be zeroed more accurately without opening the system to air and that (2) this finding is consistent across two different brands of collection systems. Finally (3) while both methods appear to be highly accurate, the closed method may have the added benefit of minimizing the risk of contamination during zeroing.

Objective: Post-concussion symptoms are nonspecific and commonly endorsed by individuals with unrelated health conditions, even without a concussion history. This study examined differences in the network structure of post-concussion symptoms, and mechanisms for symptom maintenance, between young adults with and without a remote concussion history. Observable differences in network indices may elucidate which symptoms and symptom connections are specific to concussion, compared to non-specific symptoms commonly endorsed by individuals with no concussion history.

Methods: Undergraduates (N=351; 15.4% male; 76.8% White; 2.9% Hispanic; 25.2% with a prior concussion [26.6% <1 year since injury]) from a Southeastern University reported post-concussion symptoms thrice daily for 30 days using an ecological momentary assessment design. Between-person network analysis was applied to daily responses on the 22-item Post-Concussion Symptom Scale. The psychometric networks, averaged across all days and participants, depict symptom centrality through average bridge strength (BS) and the strongest connections between central symptoms and other sequelae through average edge weights (EW). Two between-person networks were compared between undergraduates with and without a remote concussion history.

Results: Overall, in the concussion group Feeling more Emotional, Difficulty Remembering, and Sadness were the most central symptoms (BS range: 4.85-5.86). The strongest edge weights connecting central symptoms were Feeling more Emotional-Fatigue (EW=.65), Difficulty Remembering-Fatigue (EW=-.64), and Sadness-Feeling more Emotional (EW=.62). In the control group, central symptoms were Sleeping More than Usual, Difficulty Remembering, and Sensitivity to Noise (BS range: 3.14-3.54). The strongest edge weights connecting these symptoms were Sleeping More than Usual-Difficulty Remembering (EW=-.35), Difficulty Remembering-Difficulty Concentrating (EW=.56), and Sensitivity to Noise-Sensitivity to Light (EW=.75).

Conclusions: In undergraduates with a remote concussion history, affective and cognitive symptoms were prominent. After a month of daily tracking, these symptoms were shown to predominantly activate and amplify sleep-related problems like Fatigue. Future research should explore whether variability in sleep quantity and quality relates to symptoms in concussion presentations, particularly examining the effect of poor rest on academic performance. In those without a prior concussion central symptoms were mixed, highlighting the nonspecific nature of concussion-like symptoms and their relation to general, global distress. In the control group, symptom activation patterns were mixed between hypersomnia, cognitive problems, and sensory sensitivity. Heterogeneous patterns of central symptoms and symptom activations may reflect the various academic, social, vocational, and interpersonal stressors that are common in undergraduate populations. Interestingly, Difficulty Remembering was the only shared item between the groups for symptom centrality, meaning undergraduates endorsing post-concussion symptoms, regardless of etiology, report poorer memory that is salient to their presentation. Further research is needed to examine the centrality of objective cognitive deficits, separating them from the common self-reported difficulties of undergraduates navigating college coursework.

Early pediatric rehabilitation in acute care is crucial for patients with brain injuries. It allows for prompt identification and management of medical complications, such as increased tone, agitation, storming, bowel and bladder issues, and disorders of consciousness. Additionally, early engagement with rehabilitation specialists, including pediatric rehabilitation physicians, facilitates a comprehensive and coordinated approach, addressing the unique needs of these pediatric patients.

Pediatric rehabilitation physicians play a pivotal role in acute care settings, providing medical expertise and overseeing the rehabilitation process. They contribute to prognostication, helping families and care teams understand the potential long-term outcomes and plan for post-inpatient rehabilitation and long-term care.

The discussion focuses on the importance of early mobility, counseling, and family-centered care. Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) play vital roles in optimizing recovery outcomes. Effective communication and setting realistic expectations through early education with families and care teams are essential for improving patient outcomes and family satisfaction.

Post-inpatient rehabilitation care is essential for optimizing long-term outcomes in pediatric patients with brain injuries. Ongoing interdisciplinary expertise, provided through multidisciplinary clinics, is crucial for facilitating continued recovery. Effective communication, coordination, and optimization of care among healthcare professionals are key. Pediatric rehabilitation physicians play a vital role in overseeing this care, ensuring that medical goals are met, medications are managed appropriately, and ongoing rehabilitation is tailored to the individual patient's needs.

Thus, pediatric rehabilitation physicians are essential for providing comprehensive care for children with brain injuries, from acute care to long-term rehabilitation, ensuring optimal outcomes and improving quality of life.

Canadian youth rugby participation is growing and with it comes an increased risk of injuries, like concussion. Appropriately targeted prevention strategies are essential for mitigating concussion risk while promoting the health benefits of sport. Evidenced-based primary prevention strategies are available, including policy/rule changes, equipment recommendations, and training interventions. However, research suggests that such prevention strategies are variably implemented, thus limiting their impact. Examining these strategies through a sociocultural lens could provide a clearer understanding of their inconsistent implementation. Sociocultural contexts have been examined with respect to secondary (i.e., management) and tertiary (i.e., rehabilitation) prevention, but there is limited evidence that considers how sociocultural constructs influence primary prevention.

Purpose: 1) To understand how sociocultural factors influence the implementation of primary concussion prevention, and 2) understand the unique influences of the Canadian rugby context on primary concussion prevention strategies.

Methods: This project was guided by sociocultural theoretical frameworks on sport, pain and injury, and more specifically the culture of risk, masculinity, and sportsnet. We conducted semi-structured interviews (N = 6) with national and provincial rugby administrators (e.g., presidents, executive directors) and focus groups (N = 2) with provincial youth club rugby coaches across Canada (i.e., Alberta, British Columbia, Ontario). We analyzed the data using codebook thematic analysis grounded in critical realism.

Results: Four higher order themes were generated from administrators’ and coaches’ descriptions of concussion prevention in the rugby context. First, Contact for Injury Prevention emphasizes how rugby stakeholders embrace their sport’s risky nature in a more nuanced way then traditional conceptualizations of the culture of risk. Specifically, rather than a “put the body (head) on the line” attitude, stakeholders believe in preparing for the collisional nature through prevention strategies. Out with the Old…In with the New highlights how the Canadian rugby culture has begun to accept concussion initiatives and assigned concussion with an exceptional status in comparison to other musculoskeletal injuries, shifting from an old school approach (e.g., tough it out) to a newer, safer, mentality. Nothing About Us Without Us contradicts traditional conceptualizations of ‘sportsnets’ as authoritarian and emphasizes that to implement changes related to concussion prevention, an integrated approach that facilitates transmission of top-down evidence while incorporating knowledge-user perspectives is seen as essential. Lastly, Evolving Initiatives demonstrates participants’ acceptance of mandatory primary prevention programs like concussion education, but highlights that these strategies must be aligned to meet the demands (e.g., time, human resource, overload fatigue) on youth sport administrators and coaches.

Conclusions: Our results suggest a deviation from previous sociocultural evaluations of rugby that may indicate a willingness to implement prevention strategies, with partnered approaches. The findings contribute an important piece to the contextual puzzle that can assist researchers and policymakers in designing future youth sport concussion prevention strategies.

Introduction: Falls are the primary cause of mild traumatic brain injury/concussions. Older adults and those with neurodegenerative diseases are at very high risk for falls, and consequently at highest risk for sustaining concussions. Concussion rates in the older population and those with neurodegenerative diseases is largely unknown. The rates reported in recent studies is lower than expected in this demographic, and there is limited data in those with neurodegenerative disease as they are usually excluded from studies. A combination of under-reporting of falls and a lack of awareness regarding potential consequences of falls (especially head injury), results in the underdiagnosis of post-fall issues and concussions in these population. We aimed to conduct a quality assessment survey to assess clinical practice regarding falls and general knowledge of concussion symptoms in North American physicians.

Methods: We sent surveys inquiring about physician practice regarding falls and concussions through email to 1400 North American physicians working at university affiliated hospitals and who specialize in caring for older adults and patients with neurodegenerative diseases.

Results: 141 physicians (neurologists, geriatricians, primary-care physicians, psychiatrists), more than 78% of whom saw Parkinson’s disease, Alzheimer’s disease, dementia, or older adult patients weekly, responded to the survey. 71.4% of physicians either never inquired or inquired in less than 5% of their neurodegenerative disease or older adult patients, about history of falls. Over half of the physicians (51.8%) either never ask or do not consider it necessary to ask about concussion symptoms after a patient or caregiver reports a fall. The majority of the physicians (92%) knew that concussions can have lasting effects on patients and 99% of respondents recognized that a concussion could worsen their patient's cognition and mood. Over 70% of responding physicians believed that their patients can fully recover from a concussion with the same probability as any other age group if treated. Only 50% felt confident in managing post-concussion symptoms themselves.

Conclusions: Our results highlight a gap in practice amongst physicians in regard to falls and possible concussion in older adults and those with neurodegenerative diseases. The rate of physician inquiry about history of falls and concussion symptoms is very low. Failure to recognize a concussion after a fall can lead to missed opportunities for targeted interventions to address reversible symptoms. The misattribution of post-concussion symptoms to disease progression may exacerbate or accelerate symptoms of neurodegenerative disease. Due to exclusion criteria for upper age and pre-existing neurological conditions in most studies on mTBI, it is unknown how post-concussion symptoms manifest in older adults and those with neurodegenerative disease, even though they are the demographic at highest risk

Peer support is key to promote independence, inclusion, and participation according to The United Nations Convention on the Rights of Persons with Disabilities. Acquired brain injury (ABI) impairments may be severe, persistent, sometimes life-long, and affect neurocognitive, psychological, and physical functioning. The age at injury plays an essential role and impact the child’s/youth’s ability to learn new skills. ABI survivors face numerous cognitive and physical challenges that can hinder their reintegration into society. Peer support can facilitate this reintegration by supporting them to overcome challenges with cognitive, physical, and emotional issues that affect their ability to return to everyday activities. This includes education and social roles often further complicating the challenges in adolescence. There is a lack of structured peer-mentor educational programs for youth with ABI. Peer mentors are individuals who have lived experiences of life after an ABI. Peer mentors offer an unique supplement to traditional healthcare services by providing guidance, sharing personal stories, and serving as role models. The Sunnaas Foundation’s Mentor Yng program is a peer-mentor education initiative for youth with ABI. The seven-month educational program focus is on leadership, communication, and mentoring techniques that equips participants with self-leadership tools and essential mentoring skills preparing them to provide both emotional and practical support to their mentees. Mentor Yng training promotes professional integration, helping participants reconnect with education, social roles and employment. The program is module based built up around sessions with different topics delt with in focus groups and practical training related to personal goals. Self-development tasks between sessions are mandatory. Learning is facilitated by trained peer mentors across gender, experience, background and sectors from all over Norway.
The program includes practical training at the Sunnaas Foundation's Active Rehabilitation camps, where mentors apply their new skills in real-life settings. This combination of theoretical learning and hands-on experience fosters both personal and professional growth.
Research supports the effectiveness of peer mentoring in rehabilitation, showing improvements in physical activity, social integration, and overall quality of life.
We will present experiences from training and supporting young mentors with ABI in the Sunnaas Foundation’s Mentor Yng program and discuss our experiences up against newly published qualitative research based on our work. Our presentation will include discussion on how such knowledge and certification may strengthen ABI survivors role and performance in the community.

Background: Computer-mediated communication (CMC), including text messaging, social media, gaming, and videoconferencing, serves as a central means of connection and self-expression among adolescents. With 95% of adolescents having access to smartphones and 45% online nearly constantly, CMC is an integral part of adolescent life. Particularly, social media plays a critical role in enabling adolescents to connect with peers, share content, and participate in online communities. Adolescents with acquired brain injury (ABI), however, often face barriers to social participation due to motor, cognitive, sensory, communication, and behavioral challenges from their injury. While CMC may provide a unique opportunity for social engagement, there is limited understanding of how cognitive, executive functioning, and communication difficulties influence CMC use in this population. This study aimed to administer a co-designed survey to explore and quantify the patterns and preferences of CMC use among adolescents with ABI. The survey was developed using a participatory design approach through collaboration with youth leaders with lived experience of ABI, the research team, family advisors, and rehabilitation professionals.

Methods: The co-design process was guided by the Double Diamond Framework and involved the creation of the Social Media Building Blocks (SMBB) survey. The SMBB survey, as well as the Child and Adolescent Scale of Participation (CASP), and the Latrobe Communication Questionnaire - Self version (LCQ-S), were administered to adolescents with ABI, aged 13 to 21 via REDCap. Purposive sampling was used to target community-dwelling youth with ABI, recruited through a children's treatment hospital.

Results: Preliminary analysis of data from seven respondents (mean age = 15.42 years; 4 females) revealed that participants began using CMC at a mean age of 9.14 years. Common causes of injury included motor vehicle accidents, strokes, and falls. Participants reported using 3-5 social networking sites, such as SnapChat, Instagram, and TikTok, primarily for entertainment and communication with known networks (e.g., face-to-face friends), with many indicating they used CMC "almost constantly." Unique challenges for adolescents with ABI included physical and sensory difficulties (e.g., headaches, hemiparesis, vision), cognitive challenges (e.g., remembering information, attending to posts), communication issues (e.g., understanding humor, following conversations), and emotional concerns (e.g., anxiety over online identity). Participants also raised concerns about privacy, security, navigating busy interfaces, and maintaining independence online. A few indicated that rehabilitation professionals could play a supportive role in addressing these challenges.

Conclusions: Initial findings suggest that adolescents with ABI are actively engaged in CMC and face unique barriers affecting their experience. The study underscores the importance of tailoring support strategies for this population, with potential for rehabilitation professionals to assist in overcoming these barriers and enhancing social participation in digital spaces. Future steps involve continued survey dissemination to achieve a larger representative sample and refine support recommendations.

Background: Social media platforms like Facebook can help adults with traumatic brain injury (TBI) build social connections, reduce isolation, and access support networks. However, individuals with TBI use social media less frequently than their peers, often due to accessibility and usability challenges, as platforms are not typically designed with their needs in mind. Studies of social media use in adults with TBI have shown its benefits and challenges. Building on this knowledge, a Talk-Aloud study confirmed the benefits and challenges adults with TBI face on social media. The research team then employed participatory design methods to develop aids addressing cognitive and communication challenges online. A usability and feasibility study involving individuals with TBI and rehabilitation professionals led to significant improvements based on feedback.

Objectives: This study explores how individuals with TBI utilize developed digital aids over several weeks while engaging with Facebook. Specifically, this work examines (1) user perceptions of five browser-based aids designed to modify Facebook’s user interface (UI) and (2) the impact of these aids on users' social media experiences.

Methods: Thirty-nine individuals with TBI were recruited for a 4-6 week study. During this period, participants interacted with five distinct browser aids (e.g., Focus Mode) that adjusted various UI functions and visuals on Facebook to better accommodate TBI-related challenges, such as visual clutter and cognitive overload. Participants provided daily feedback on their experiences with each aid, along with pre-post surveys assessing their social media usage patterns, life satisfaction, and perceptions of social media post-TBI. Additionally, participants completed a final evaluation of the aids and overall study experience.

Results: Users with TBI generally found the aids beneficial, particularly those reducing visual clutter and information overload. Participants reported improved ease of use and comfort when interacting with Facebook, indicating that the aids mitigated some cognitive demands of social media use. A pre-post comparison showed increased life satisfaction during the study. However, participants also identified unmet needs that the current aids did not fully address, highlighting areas for further development. Reflections on the methodology underscored the challenges of conducting evaluations in naturalistic settings, providing valuable insights for future research.

Conclusions: This study demonstrates that browser-based aids designed to address the unique challenges faced by social media users with TBI can enhance their online experiences. The positive feedback from participants supports the potential for integrating similar functionalities into mainstream social media platforms. By doing so, these platforms could create more inclusive environments that allow users with TBI to engage meaningfully without the common barriers to participation. Future research should investigate additional features to address the evolving needs of this population, further refine the design of these aids for broader application, and explore their integration into rehabilitation settings.

Background: People with acquired brain injury (ABI) often experience a spectrum of physical, cognitive, and emotional changes. Wellness after ABI is independent of functional status, suggesting that enhancing wellness can elevate the quality of life and foster a sense of purpose, even though underlying changes may remain. An emphasis on wellness redirects rehabilitation strategies towards promoting well-lived lives, considering meaningful activities that enhance the daily experience of individuals with ABI. The Unmasking Brain Injury project guides individuals with ABI in telling their brain injury story.

Methods: Guided by the Six Dimensions of Wellness (DoW; cognitive, physical, emotional, occupational, spiritual, and social health), this study aimed to understand individuals' narratives comprehensively and identify facilitators and barriers to wellness. Data were collected from the publicly available Unmasking Brain Injury website (http://unmaskingbraininjury.org/) and hosted Unmasking events available as of 1/1/24. Narratives from people with ABI (n=1019) were analyzed in three phases: 1) document-level content analysis, 2) communication unit (c-unit) content analysis based on DoW, and 3) c-unit and full narrative aggregate sentiment analysis. An inductive coding approach was applied to the intention of storytelling, with deductive coding for DoW. Sentiment analysis categorized sentences as positive, negative, neutral, or mixed.

Results: Most masks were created by people with traumatic brain injury (TBI; n=681), followed by stroke (n=190) and other ABI (such as brain bleeds or infections, n=148). We found that people with ABI used the narratives to share their stories with others and personally reflect on their ABI. Individual c-units contained all six DoW and an additional dimension of recreation. Most c-units were related to emotional, spiritual, physical, social, cognitive, and, to a lesser extent, occupational and recreational wellness. Sentiment analysis reflected positive c-units related to spiritual, social, and recreational health, which may be representative of facilitators of wellness. Negative c-units may be considered barriers to wellness, primarily physical, cognitive, and emotional health. Emotional health was also identified as mixed, emphasizing the challenge of pursuit of wellness post-ABI.

Discussion: Grounded in personal experiences, Unmasking Brain Injury narratives serve as a powerful tool for people with ABI to reveal dimensions of wellness that serve as facilitators of wellness (spiritual, social, and recreational health) and those that may act as barriers to wellness (physical, cognitive, and emotional health). Given most people who created a mask used it as a platform for community education, as well as personal reflection, this modality of communication may be particularly appropriate for facilitating conversation of holistic wellness after ABI. Future work will use mask-making in clinical or rehabilitative settings to support motivational interviewing during the assessment and treatment of ABI.

Background: Acquired brain injury (ABI) can affect functioning and quality of life through a wide range of consequences. For example, people may experience changes in sensory, physical, cognitive, communication, language, and personality and behavior domains. Given the potential for these effects to be long-lasting, emotional reactions are common. A loss or deficit in previous modalities of self-expression, such as comprehension, expression, or attention and recall, can create a sense of disconnection from others and strain existing relationships. Visual art is a powerful modality of expression that supports individuals in describing their thoughts and emotions in tangible forms. Art provides an avenue to relay abstract concepts and feelings that are difficult to convey with words or exist beyond linguistic abilities. The Unmasking Brain Injury Project harnessed a method and protocol for sharing and displaying the experience of ABI by creating masks, which are three-dimensional face coverings or representations. Artists use different techniques to decorate and personalize masks, resulting in various designs. Masks can carry symbolic meaning and convey emotions, characters, or stories.

Methods: Given the widely used format of mask-making for brain injury awareness and advocacy, this phenomenological qualitative study explored how people with ABI used art and design related to emotions and prompts in the Unmasking Brain Injury protocol. The publicly available digital catalog of photos of masks and accompanying descriptions created by people with ABI was used in this evaluation (n=1049). Hybrid inductive/deductive reflective thematic analysis was used to evaluate mask-making patterns and their relationship to identified emotions and colors.

Results: Colors and their associated meanings were matched mainly to the identified emotions (87%) in the Unmasking Brain Injury Protocol. However, many narratives elaborated on how or why the emotion was experienced. Narratives were then inductively evaluated to identify elements related to the emotion represented. Seventy-one percent of masks expressed pain or loss; 45% displayed a multiplicity of experiences (positive and negative), and 21.6% presented positivity or purpose as a prominent emotional experience.

Discussion: People with ABI used visual art to display many emotions, including the struggle of ambiguous loss and using purpose and positivity to cope. Visual art may be well posited as a medium for expressing complex or intangible emotions or experiences, as it doesn’t rely solely on language for expression and can be expanded upon given a simple prompt. Clinical applications can include mask-making to identify an individual's perspective of the consequences and long-term outcomes of their ABI. This presentation will include clinical experience setting up, prompting, and supporting an Unmasking Event and using masks in brain injury awareness, advocacy, and survivor-focused perspectives.

Background: Overdose-induced hypoxic brain injury is a devastating yet understudied consequence of the global toxic drug crisis. Non-fatal opioid poisoning triggers respiratory depression, reducing cerebral blood flow and causing irreversible neuronal damage, leaving survivors with long-term disability. Previous research raises two key questions: How do we recognize overdose-induced brain injury, and how do we best support those affected? Given the lack of evidence, stakeholder guidance is needed to produce actionable insights with practical utility for knowledge-end users. Therefore, this mixed-methods study engaged stakeholders in a workshop to generate priorities for research and clinical practice on recognizing and responding to overdose-induced hypoxic brain injury.

Methods: Data were collected during a one-day (6-hour) workshop. Participants were 14 stakeholders in the brain injury and substance use communities (Mean age = 46.14 years, SD = ±14.59 years, 57% female), including people with lived experience of brain injury (n = 6) and/or overdose (n = 3), family members of people with lived experience of brain injury (n = 4) and/or overdose (n = 4), service providers (n = 2), government representatives (n = 4) and healthcare professionals (e.g., RNs, R.Psychs., n = 6). Individuals could identify with more than one stakeholder group. Using the World Café method, stakeholders participated in small group discussions (3–5 participants per group) over two sessions (i.e., generation, prioritization). Discussions led to the generation of over 50 ideas, which were then collated, themed and rank-ordered by priority (urgency, impact, feasibility) through group voting. All quantitative analyses were conducted using R (version 4.3.3).

Results: Stakeholders’ discussions and subsequent prioritization evaluations identified 18 priorities for research on recognising (e.g., what barriers currently exist for training clinicians to recognize overdose-induced brain injury?) and responding (e.g., what are the most evidence-based and cost-effective treatment modalities?) to overdose-induced brain injury. Similarly, 14 clinical practice priorities were identified across the recognition (e.g., standardizing discharge diagnoses) and response (e.g., developing evidence-based guidelines for acute care) domains. Ideas were organized and rank-ordered by stakeholders’ priority evaluations in each domain, for both research and clinical practice. The full list of priorities touches on a wide array of tools (e.g., screening and diagnostic measures), technologies (e.g., electronic medical records) and approaches (e.g., trauma-informed services), spanning across the acute to long-term stages of care.

Conclusions: This study identified community-driven priorities for recognizing and responding to overdose-induced hypoxic brain injury. These findings serve as a source of knowledge where there currently is none, providing insight into stakeholders’ priorities for research and clinical practice. Healthcare professionals, researchers and funding agencies should use these priorities to inform their agendas and address stakeholders’ most urgent needs, fostering meaningful improvements to the current state of empirical knowledge and clinical care.

Background: Concussions are a health concern for many Canadians. Despite the frequency of these injuries, there remain gaps in research and care. Accordingly, the TRANSCENDENT Concussion Research Program, an initiative funded by the Ontario Brain Institute, was developed to support the advancement of concussion research and care for all Canadians. A key pillar of the TRANSCENDENT program is Knowledge Translation (KT). KT supports dissemination and implementation efforts and can ensure that the latest evidence and best practices are shared with and applied by key knowledge users, including children, families and healthcare professionals. The objectives of the present study were to assess the reach of the initial KT efforts for TRANSCENDENT and to identify opportunities for future KT initiatives.

Methods: A KT team was formed comprised of concussion researchers and KT specialists. The KT team developed a framework, guided by the Knowledge to Action Framework, to help build an initial KT plan to spread awareness around the research program and its activities. Key components of the KT plan included the (1) development of community-facing materials, including a website, social media account, podcast, and informational handouts, (2) creation of clinician and research-focused materials and learning opportunities to facilitate knowledge sharing and advance concussion care and, (3) formation of a Community Advisory Committee (CAC) to support future KT initiatives. Information regarding reach was gathered through website and social media analytics from November 2023- April 2024.

Results: A public-facing website (transcendentconcussion.ca) and X account were created (@TRANSCENDENT_KT) to share information about the research program. Together, the website and X posts were viewed 9,557 times. Two informational handouts to support the research program were developed and shared at community outreach events, and one community-facing podcast episode featuring a pediatric physician was recorded. Dissemination of the latest concussion research and clinical recommendations included 5 speaker series events held for concussion researchers and medical professionals who work with pediatric concussion. Two KT products were developed with specific recommendations for health professionals to support concussion care. Finally, an initial CAC made up of individuals with lived concussion experience (n=6) was formed.
Discussion: Initial KT efforts, guided by a KT Framework, allowed for the broad dissemination of information and materials related to the TRANSCENDENT program. There is a need for further KT efforts, particularly directed at the community, to get the latest concussion information to the broader public. Future efforts will be identified and implemented alongside the CAC to ensure that the voices of key end users are being reflected in the dissemination and implementation processes. As KT efforts continue, there is a need to evaluate them to further knowledge around best practices for disseminating and implementing concussion research.

Introduction / Rationale: Post-stroke fatigue (PSF) is a significant issue in stroke survivors, particularly during the subacute and chronic phases of recovery. PSF prevalence range between 25-85% and can severely limit engagement in rehabilitation and daily functioning. Despite its high prevalence, PSF remains under-researched and under-treated, with mechanisms and optimal management strategies still unclear. This review seeks to synthesize the existing evidence on PSF, specifically focusing on patients in the subacute and chronic phases of stroke, and to identify gaps in the literature to inform clinical practice.

Objectives: The purpose of this scoping review is to identify and summarise the existing literature on fatigue in post-stroke patients in subacute and chronic phases of recovery in order to update the evidence base. The objectives was focused to the definitions, theoretical models, influencing factors and to summarize the assessment methods in adult patient after stroke.

Method / Approach: A systematic search was conducted across databases including PubMed, OVID, Scopus, and Web of Science, covering studies published from 2014 to 2024. Keywords included “post-stroke fatigue,” “subacute,” “chronic,” “fatigue assessment” and “fatigue management”. Eligible studies involved adults in the subacute or chronic phase post-stroke and addressed PSF in terms of prevalence, influencing factors, assessment, or fatigue management. Data extraction included study design, participant characteristics, outcome measures, and intervention effectiveness. The findings were synthesized thematically to identify trends, knowledge gaps, and practice implications. Exclusion criteria included studies focusing on acute stroke phases or non-adult populations.

Results and or Practice Implications: A total of 683 studies were found. 451 remained after removing duplicates. Abstract and title screening further reduced this to 139 articles. Full-text review was conducted using inclusion criteria, resulting in 26 studies included in the final review that fall into one of the categories: definition of PSF, PSF theoretical models, PSF assessment.
The results indicate that PSF is most prominent in the subacute and chronic phases with higher prevalence in those with comorbidities such as depression or sleep disorders. Fatigue is often underdiagnosed due to the lack of standardized tools specifically designed for stroke patients in these phases. Available assessment tools such as the Fatigue Severity Scale (FSS) and the Fatigue Impact Scale (FIS) are commonly used but lack stroke-specific validation.

Conclusion: PSF in the subacute and chronic phases is a complex condition requiring targeted assessment and intervention strategies. This scoping review highlights the need for standardized diagnostic criteria and more robust RCTs to produce the evidence for recommendations in clinical practice. The review further highlights a critical need for multidisciplinary approaches and individualized rehabilitation programs tailored to fatigue management.

Context: Individuals living with moderate to severe traumatic brain injury (TBI) often face obstacles to residential autonomy. Technological innovations integrated into their daily environment have the potential to facilitate participation in daily activities and promote housing stability. However, little research has explored the acceptability of these innovations for individuals with TBI, their families, and caregivers. This gap hinders the adoption of these innovations by the individuals concerned and their loved ones.

Methods: In this mixed-method study, we conducted focus groups with TBI residents, close relatives, and staff from a specialized residential setting to explore the prospective acceptability of an AI-based environmental support innovation aimed at enhancing the residential autonomy and stability of individuals living with TBI. We also used the Unified Theory of Acceptance and Use of Technology (UTAUT2) questionnaire to provide an objective assessment of the innovation’s acceptability for end-users.

Results: Thirteen individuals (residents and relatives) and two caregivers participated in two distinct focus groups and individually completed the UTAUT2 questionnaire. Overall, the prospective acceptability of the innovation was positive, although some concerns were raised, particularly regarding the availability of human contact, the robustness of the system in emergencies, and the potential burden on caregivers, for example, in cases of inappropriate use. UTAUT2 results show that the low effort required and the facilitating context provide a good balance against the efforts needed to change daily habits and use the system.

Conclusion: Technological innovations are welcomed to facilitate daily autonomy and housing stability for individuals with TBI. Key factors for the adoption of these technologies include an optimal match with daily communication and usage habits and minimizing caregiver overload to allow them to spend more quality time with residents.

Introduction: Traumatic brain injury (TBI) is a common neurological condition worldwide, leading to disabilities that are often permanent and require individualized care. These disabilities put individuals at high risk of precarious housing situations. However, little is know about the residential status of individuals living with a TBI and about the facilitators and obstacles to their housing stability.

Goal: The aim of this study is to conduct a scoping review to explore the housing situations of the TCC population, as well as the facilitators and barriers to their residential stability.

Methods: A systematic scoping review was performed. With the help of a specialized librarian, we searched three different scientific databases. Articles were screened, selected and extracted individually by the researchers. The emerging data were classified according to the Modèle du développement humain - Handicap production process theoritical model.

Results: 21 articles were included in the synthesis. The results show that around 85% of people who have had a TBI live at home with one or more people. Facilitators and barriers to residential stability were classified into the three broad categories of the MDH-PPH model. Environmental factors, particularly the design of the physical micro environment, followed by human support, emerged as the most commonly reported factors influencing residential stability. Personal factors are also of secondary importance. Lifestyle habits have been little documented in the literature as determinants of residential stability.

Discussion: The results are comparable to those of others individuals living with neurodivergences and highlight the importance of environment to overcome handicap situation in housing. However, other factors such as life habits have been little studied and can be promising candidate for further studies about residential stability of individuals with TÉBI.

A disorder of consciousness (DoC) is a common sequela of severe acquired brain injury (ABI) and results from an interruption in the complex interplay between arousal and awareness. The acute period of DoC (<4 weeks) following an ABI may offer a unique window of rehabilitative opportunity to maximise early consciousness recovery and subsequently promote long term functional recovery and quality of life (Molteni et al., 2021). However, individuals presenting with a DoC are a complex rehabilitative population. These individuals are dichotomously at risk of overstimulation due to the potential for compounding cognitive deficits and associated cognitive fatigue, and under stimulation due to a profoundly impaired ability to actively participate in therapy. Hence, there is an argument that therapeutic interventions based on sensory stimulation, including music, should be considered the cornerstone of DoC rehabilitation (Edlow et al., 2021).
Current evidence supports the use of music-based interventions in the assessment and treatment of adults (aged 18+ years) presenting with a prolonged DoC (>4 weeks). Music interventions are reported to stimulate both the behavioural and neurophysiological markers of consciousness (Magee, 2018; O'Kelly et al., 2013). However, the inherent distinctions in the brain's morphology, size and functional connectivity between children and adults means that children exhibit a unique and developmentally specific response to severe ABI. Moreover, recent findings in music neurosciences highlight discernible differences in how children process music and other auditory stimuli (Bower et al., 2021). Therefore, models of ABI recovery and rehabilitative strategies developed in adult contexts are not immediately translatable to the paediatric population and child specific research is needed.
This presentation will include an overview of evidence supporting music-based interventions for children presenting with a DoC followed by the results of a prospective crossover multiple baseline case study. An 11-year-old child was recruited to this study following a severe hypoxic brain injury. They participated in three experimental sessions on day 23 of their hospital admission. During each experimental condition familiar song, speech and noise auditory conditions were presented in random order while time-locked video-EEG was collected. Descriptive statistical analysis indicated that across the three experimental sessions there were a greater number of movements and behavioural responses during the song condition compared to the speech and noise auditory conditions. Further, an increase in the broadband EEG signal in the left temporal region was unique to the song condition.
Results of this single case study objectively support that familiar song may be a superior auditory stimulus for eliciting responses indicating changes in arousal and awareness in a child presenting in an acute DoC.

Introduction: Individuals with a traumatic brain injury (TBI) may experience a wide range of changes post-injury. Individuals with TBI may have cognitive and physical challenges such as attention and mobility problems; they may also encounter social difficulties such as stigma and discrimination, which may stem from a lack of public education and awareness. However, the current public perceptions on TBI are not known.

Objective: To identify current evidence on public perceptions on TBI.

Methods: A scoping review was conducted using the following databases: MEDLINE, CINAHL, Embase, and PsycINFO. Peer-reviewed journal articles were reviewed from inception to April 2024. Articles were included if they: 1) presented data on perceptions about TBI, 2) included adult participants who were members of the lay public, and 3) were published in the English language. Articles were excluded if they were reviews or dissertations, assessed perceptions about pediatric TBI, or recruited participants who had extensive knowledge or training about TBI.

Results: 3872 articles were obtained from the databases and 112 full-text articles were reviewed. Of those, 18 were included in our study, reporting on various antecedents and beliefs about TBI. Antecedents of age, sex, and education reported inconsistent patterns on the effect on public perception. However, individuals who had more personal experiences with brain injury (i.e., family/friends with brain injury) had fewer misconceptions about TBI. Most individuals from the public had accurate knowledge about prevention, knowledge, and TBI outcomes. However, topics of memory loss, coma and unconsciousness, recovery and rehabilitation after TBI reported higher misconceptions. Additionally, findings indicated that the public were more likely to misattribute behaviors of a TBI to another cause if the injury was not visible and perceive individuals with TBI as lower in competency.

Conclusions: Findings from our study identified existing perceptions of TBI. A lack of public understanding about this injury can exacerbate stigma, cause barriers to receiving support, and increase physical and mental health difficulties for individuals with TBI. Our findings can help guide future research to implement practices to reshape public perception about TBI and facilitate increased recognition and acceptance about life after TBI.

Introduction: After a traumatic brain injury (TBI), an individual might experience varied outcomes due to the environment, their personality characteristics, and injury-related impairments. Participating in research studies may be difficult for individuals with TBI due to a range of health-related and personal problems. For example, participants may have trouble recalling information or feel vulnerable when sharing personal experiences. It can also be challenging for researchers to navigate data collections sessions as they may have limited resources and strategies to create a person-centered environment.

Objectives: To explore researcher experiences of conducting mixed-methods research with individuals with moderate to severe TBI and to describe approaches to help improve researcher-participant relationships.

Methods: An autoethnography study was conducted, analyzing the experience of a novice researcher conducting a mixed-methods study with 16 participants with moderate to severe TBI. Data collection consisted of transcripts from participant interviews, questionnaire sessions, and reflexive notes by the researcher. Reflexive thematic analysis was used to generate themes of researcher experiences when interacting with participants during data collection.

Results: Three themes and three key strategies were identified, relating to challenges and facilitators to form a person-centered environment. First, ‘creating connections’ focuses on participant experiences that may have been inadvertently minimized and the need to build rapport with participants before data collection. Second, ‘asking the right questions’ examines the need for researchers to consider how participants will perceive questions and being aware of potentially sensitive words that are already established in standardized quantitative questionnaires. Last, ‘wearing academic armor’ explores how researchers can adapt and adjust to each participant to create a personalized approach, as well as being open to participant emotions that may arise when talking about their injury. Three key strategies to facilitate research-participant relationships were identified: (1) using a multimethod design to enhance and supplement the research investigation, (2) collaborating with stakeholders as well as participants prior to the study to increase the suitability of study protocol, and (3) employing a strong active listening approach to help navigate the conversation and discern participant verbal and non-verbal cues.

Conclusions: This study examines researcher experiences when collecting data with individuals with TBI and provides generalizability to other disability populations. These experiences and strategies can serve as a tool for researchers to design their study using these approaches and improve the data collection process for participants with TBI.

Background: Acquired Brain Injury (ABI) is a leading cause of death and disability in children and youth. ABIs can impact cognition, physical abilities, emotions, and behaviours. Despite the broad consequences of these injuries, educators are unaware of ABIs and how they may impact youth at school. To fill this gap, we created an online professional development module, TeachABI, about ABI and supporting students with ABI in Ontario schools. We previously reported the knowledge and self-efficacy outcomes of TeachABI in our full sample of participants. This abstract presents exploratory subgroup analyses examining how participants’ prior knowledge and self-efficacy influence module outcomes.

Methods: Ontario educators (N = 50) completed surveys (ABI knowledge, knowledge application case study, self-efficacy) at three time points: pre-module (T1), post-module (T2), and 60-days post-module (T3). Some participants (n = 29) completed a semi-structured interview about their experience with TeachABI at T2, but this data is not presented herein.

Analysis: To explore how baseline scores related to change from T1-T2 and T1-T3, we performed linear regressions with baseline score as the predictor. To examine whether participants with high-baseline scores benefitted from the module, we performed Friedman’s test with the subgroup who had baseline scores +1 SD above the mean (n = 7-9). We used a nonparametric MANOVA to compare participants with low-baseline scores (-1 SD below the mean, n = 6-9) to those with high-baseline scores across time.

Results: Linear regressions show that as baseline scores increase, T1-T2 change scores decrease for knowledge (R2 = .69, F(1, 43) = 94.56, p < .001) and self-efficacy (R2 = .81, F(1, 45) = 188.7, p < .001). The same was found for T1-T3 scores (knowledge: R2 = .59, F(1, 43) = 62.45, p < .001; self-efficacy: R2 = .57, F(1, 45) = 60.9, p < .001). Following a significant Friedman’s test, Bonferroni-corrected Wilcoxon signed-rank tests (α = .016) showed that high-baseline participants’ scores were not significantly different between T1-T2 (Z = -2.11, p = .035) or T1-T3 (Z = -1.90, p = .058). Friedman’s test of self-efficacy scores indicated no significant differences across time ( 2(2) = 4.90, p = .086). MANOVA results suggested that low-baseline participants had the same final scores as the high-baseline group for both knowledge and self-efficacy.

Implications: Previous whole-sample analyses suggest that TeachABI increases educators’ ABI knowledge and self-efficacy for supporting a student with ABI. The subgroup analyses provide nuance to these findings; Some educators receive little benefit from TeachABI, while others benefit enough to meet their peers’ level after TeachABI. These results will be considered when analyzing interview data, to see whether high-baseline participants report qualitative benefits from the module, and in future studies examining the effectiveness of TeachABI in a larger sample.

This is the case of a 28-year-old female athlete with past medical history including asymptomatic Ebstein anomaly who suffered anoxic brain injury after unwitnessed out-of-hospital cardiac arrest with unknown downtime requiring cardiopulmonary resuscitation and automatic external defibrillator shock three times prior to return of circulation. The patient was admitted to inpatient rehabilitation where her course was remarkable for severe paroxysmal sympathetic hyperactivity (PSH) and paroxysmal autonomic instability with dystonia. PSH is a syndrome of dysregulated sympathetic outflow resulting in episodes featuring vital sign derangement and increased motor tone and posturing. This patient with anoxic brain injury in the context of robust cardiovascular reserve displayed severe and persistent PSH. In addition to careful multidisciplinary management involving personalized nursing and therapy efforts, the treatment of this patient's PSH included a stepwise amplification in pharmacotherapy based on clinical practice guidelines. Nevertheless, the patient's PSH remained refractory to high doses of gabapentin, propranolol, and baclofen, as well as treatment with clonidine, dantrolene, transdermal fentanyl, enteral hydromorphone, and intravenous morphine. Her course was complicated by pain, contracture development, pressure injury, and cortical atrophy. The dysautonomic signs and symptoms remained poorly controlled until the patient was started on scheduled intravenous diazepam. Benzodiazepines have been utilized as treatment for PSH symptoms including abnormal tone; however, its broader use among patients with brain injuries is often limited due to concerns for its effects on cognition and neurorecovery. Here we present the case of a young, previously healthy female whose anoxic brain injury led to severe autonomic dysfunction and dystonia requiring relatively high dose intravenous benzodiazepines to achieve adequate control. We conclude that judicious use of benzodiazepines may provide a valuable tool in young, otherwise healthy patients for early control of dysautonomic tone to prevent secondary complications following brain injury.

Background: Aphasia affects a third of all stroke survivors and > 50% of people with other acquired brain injuries, hindering effective communication between patients and healthcare professionals. Aphasia makes it difficult for patients to get the attention of healthcare professionals, communicate basic healthcare needs, and get oral and written health information. Consequently, initiatives towards reducing the communicative barriers in healthcare is needed, including the use of alternative and augmentative communication and adapted written materials, but also “top-down” system changes. Such initiatives include training of medical staff, often labelled communication partner training (CPT), to enable supported communication. A Danish CPT program, KomTil, was co-developed with collaborators with aphasia, significant others of people with aphasia, and multidisciplinary healthcare professionals across sectors, and the current study aimed to investigate:

1: Immediate and long-term possible benefits of CPT KomTil on knowledge and skills
2: Possible predictors of benefits of CPT KomTil

Conclusions: Participants included staff with different professional backgrounds providing neurorehabilitation to people with aphasia in hospital or municipalities. Participants received training in CPT KomTil, and knowledge and skills were assessed using the Health Professionals and Aphasia Questionnaire (HPAQ) before training, six to eight weeks post-training, and one-year post-training. HPAQ consists of 16 items answered on a visual analogue scale concerning the following domains: Knowledge, skills, attitudes and emotions, practice, and environment. The total score of the HPAQ ranges from 1-100. Data were analysed using linear mixed-effects regression models.

Results: A total of 240 healthcare professionals participated in the survey. The HPAQ total score changed over time (χ2(3) = 328.8; p < .001). Compared to baseline, HPAQ improved by 14.5 points (SE = 0.76; p < .001) 6-8 weeks post-training, and by 13.1 points (SE = 0.92; p < .001) one-year post-training. Sector and years of experience were significant predictors of perceived benefit. Healthcare professionals at the municipalities reported greater immediate improvements compared to hospital staff (χ2(3) = 9.9, p = .02). Among hospital staff, acute units reported greater improvements than rehabilitation units (χ2(4) = 22.6, p < .001). Professionals with less experience (≤ 5 years) reported greater improvements compared to more experienced staff (> 5 years) (χ2(3) = 18.2, p < .001). There was no difference across three groups of professions (therapists vs. nurses and assistants vs. others), (χ2(8) = 13.5, p = .10).

Conclusions: The participating healthcare professionals reported benefits of the Danish CPT program indicating that they perceived themselves and their work environment as more competent for health communication with people with aphasia after having received training in the CPT scheme, and the benefit was maintained one-year post-training. Furthermore, healthcare professionals at municipalities and acute units reported greater benefits, as did healthcare professionals with fewer years of experience.

Introduction: COOK, a cognitive assistive technology, was developed to support autonomy in meal preparation for adults living with traumatic brain injury (TBI). As part of a user-centered design approach, COOK was co-developed and implemented in an iterative way in an alternative residence. During this period, a close collaboration was established with key partners of the residence. This study aimed to examine their perspectives on the implementation processes, focusing on facilitators and obstacles encountered, their roles, concerns, and favored strategies for hurdles arising during implementation.

Material and Methods: A holistic qualitative case study was conducted, the case representing the residence. Over 14 months, 35 group interviews were held during the implementation phase of COOK involving key partners of the residence (2 managers, 3 practitioners and 4 caregivers), 3 researchers and 3 male residents (March 2016 to June 2017). These group interviews were thus analyzed using the thematic content analysis.

Results and Discussion: Results show that key partners established their roles in managing the residence in terms of its finances and its residents living with TBI. A communication structure was quickly established where each partner shared their expertise to address obstacles related to the implementation process. Identified obstacles and concerns primarily related to the unique limitations of the residents’ abilities, combining research and clinical objectives, and the sustainability of the culinary assistant after the research’s team withdrawal. Main strategies adopted included adjusting the project to the alternative residence’s reality, regular monitoring of the implementation for necessary updates, building a trusted alliance with residents and managing costs related to COOK’s implementation.

Conclusions: The implementation of COOK to optimize autonomy in meal preparation for adults with TBI is a complex process, its key components must be carefully considered to ensure the effective integration of assistive technology across various settings in the broader effort to foster more inclusive societies.

Background: In most adults, concussion symptoms resolve within 4 weeks, but up to 30% experience persistent symptoms beyond one month, affecting their return to work (RTW). This study aimed to identify factors predicting prolonged RTW at 6 weeks post-injury.

Methods: We recruited adults (18-65 years) diagnosed with concussion (ACRM 2023 criteria) from Foothills Medical Centre Emergency Department (ED; Calgary, AB) within 7 days of injury. During their initial visit, participants completed demographic questionnaires including information about their current occupation and injury characteristics (i.e. mechanism of injury and previous concussions). Information on RTW at 6-weeks post-injury was collected as part of the Extended Glasgow Outcome Scale (GOS-E). Descriptive statistics, one-way ANOVA, and multinominal logistic regression tests were used to describe and compare three groups: 1) those who returned to work at full capacity (Full RTW); 2) those who returned to work at a reduced capacity (Partial RTW); and 3) those who had not returned to work (No RTW), at 6-weeks post-injury.

Results: Seventy-eight adults with concussion were recruited from the ED (51% female, 39.1 土 13.3 years). At 6 weeks post-injury, 32 (41.0%) individuals were lost to follow-up/withdrew, 28 (35.9%) had a full RTW, 10 (12.8%) had a partial RTW, and 8 (10.3%) had no RTW. Those who were lost to follow-up differed in age from individuals who did not return to work (Dropout 34.8 土 12.6, No RTW 48.6 土 8.3, p=0.01), but did not differ from those who remained enrolled in the partial and full RTW groups. The three RTW groups did not differ in age or sex (Full 42.9 土 13.7, 23.9% female; Partial 34.3 土 11.3, 17.4% female; None 48.6 土 8.28, 10.9% female; p=0.055 and p=0.07, respectively). In the multinomial regression, age (x²=10.94, p=0.004), sex (x²=20.62, p<0.001), pre-injury occupation (x²=32.75, p=0.008), and mechanism of injury (x²=24.15, p=0.007) significantly predicted RTW outcomes at 6 weeks, while previous concussions did not (x²=4.59, p=0.10). Notably, females were more likely to return to work at a reduced capacity than a full RTW (β=12.1, SE=5.48, p=0.027). Pre-injury occupations of females with a partial RTW at 6 weeks included education (37.5%), business (25.0%), medical (12.5%), and social service (12.5%).

Conclusions: Age, sex, pre-injury occupation, and mechanism of injury were significant predictors of RTW at 6 weeks post-concussion. Understanding these predictors can help guide personalized post-concussion management and support for individuals struggling to resume work fully.

On September 16, 2018, my medical career ended. It wasn't due to a terrible mistake with a patient’s care or falsified tax returns. Nor was it a sudden epiphany of self-doubt in the face of a patient’s tragedy. I had become accustomed to the onerous expectations of a professional life filled with clinical crises and administrative torment. I took my charmed life in Western Australia for granted. I was Australia’s longest-ever serving Medical Director for organ donation.
Pride really does come before a fall.
On a damp, chilly morning, descending a steep, slippery road into Apollo Bay on the Great Ocean Road, I cycled head-on into a street sign. I don’t remember any of the bad stuff—the broken neck, the brain damage, ventilated and restrained for a week while my family held a vigil at my bedside.
Time passed slowly. Six years.
I was sitting at a Brain Injury Conference in Sydney in May 2024, one I have spoken at in the past. I listened intently as esteemed medical presenters and inspirational patients spoke about brain trauma. I became angry, and I couldn’t say why.
Then it struck me.
I am brain damaged, but I am not a patient anymore. I am registered as a doctor, but I am not a clinician anymore. It’s time for me to leave the warm shelter that rehabilitation provided and stride out again into the world. That’s what rehab really means. Getting back in the game.
We brain injury patients struggle for identity and meaning in our new lives. It turns out that each of us must decide who we are for ourselves.
I am a writer now, a rookie, a resident.
“The greatest ally of the physician is time,” my first medical consultant used to recite before each ward round.
I remind myself of that incantation when the black dog interrupts my morning ocean swim. I won't ever be a doctor again, and I am acutely conscious that I am much luckier than other trauma victims.
I'm finally done trying to remember what happened yesterday; today and tomorrow are much more important.

Objectives: Adults aged 65 and older are at an increased risk of falls and subsequent mild traumatic brain injury (mTBI). Exercise intolerance is a common consequence of mTBI, defined as the inability or decreased ability to perform exercise at an age-appropriate level, duration, or heart rate (HR). Limited evidence is available to assess exercise intolerance in older adults who have sustained a mTBI. Previously validated exertion intolerance protocols, such as The Buffalo Concussion Treadmill Test (BCTT), have primarily assessed exercise intolerance in adolescents and those who have experienced sports-related concussions. The Older Adult Treadmill Test (OAT) serves as a modification of the BCTT to allow the assessment of exercise intolerance in the older adult population. This study aimed to assess the clinical feasibility based on the time taken to complete the OAT in a group of healthy older adults.

Methods: Nine participants were aged 66-89 years (mean age 74 ±7 years; 5 females) without a history of mTBI or pathology that would limit participation in an exercise test. Each participant completed the OAT while wearing a Polar H10 to allow for continuous monitoring of HR. Participants begin the test by ambulating on a treadmill at 80% of comfortable gait speed at 0% incline. Every 90-second stage, the treadmill incline increased by 1%. If participants reached a treadmill incline of 10%, treadmill speed increased by 0.4 mph per stage with a constant 10% incline. During each stage, recordings were taken on the Borg Rating of Perceived Exertion (RPE), VAS for symptom severity, and HR. Participants progressed through each test stage until one of the following was achieved: HR equal to 90% of age-predicted max HR; RPE of 17; the participant asked to stop the test. Participants were considered exercise intolerant if the test was terminated before reaching their target HR.

Results: Eight of 9 participants (89%) reached test termination by achieving 90% of age-predicted maximal HR. One participant stopped after reaching an RPE of 17 at 88% of his maximal HR. The mean time of completion was 14.7± 5 minutes. No adverse events occurred. There were weak negative correlations between the time to complete the OAT and age or starting HR.

Conclusions: Healthy older adults completed the OAT without adverse events or excessive fatigue. The average time for completion of the OAT was less than 15 minutes, indicating the OAT is a clinically feasible assessment. Additional research is needed to assess the safety and clinical utility of the OAT in older adults after mTBI.

Background: Mild traumatic brain injuries (mTBI) are prevalent during early childhood, (i.e. from birth to five years of age). Early childhood is a sensitive period for the development of cognitive and social skills; thus, sustaining mTBI could impede their normal course. Despite this, the consequences of early mTBI are understudied. Some studies suggest that long-term difficulties in behavioral and social domains can occur (Crowe & al., 2012; Gagner & al., 2018; Lalonde & al., 2018, Yengo-Kahn & al., 2021). During early childhood, parent-child interactions are at the heart of a child's social environment and the quality of these relationships plays a critical role in the development of later social relationships (Bowlby, 1962; Ruprecht & al., 2016). The quality of parent-child interactions depends on factors related to the members of the dyad, such as parental stress and burden and child behavior (Hoff & al., 2002). Lalonde and colleagues (2020) showed that the quality of the parent-child relationship was diminished in children six months after mTBI compared to non-injured children. A recent study also shows that one-week post-mTBI, the quality of the parent-child relationship was suboptimal for most dyads (Yumul & al., 2024). However, this was an exploratory study with a small sample (n = 9). Further studies are therefore needed to explore whether parent-child interaction quality is reduced in the acute or subacute phase post-injury. This study aimed to document the quality of the parent-child relationship ten days post-injury post early childhood mTBI.

Methods: Children aged 12 to 72 months (M= 42 months; 44 boys) who sustained mTBI (n = 51) or a minor orthopaedic injury (n = 18) were recruited from three pediatric emergency departments and compared with typical developing children (community controls, n = 17). The quality of the parent-child relationship was assessed using an adaptation of the observational Mutually Responsive Orientation Scale (MRO) ten days following the injury. Interactions were coded according to three subscales of the MRO; Harmonious Communication, Mutual Cooperation, and Emotional Ambiance. A total score was computed by adding together all the subscale score.

Results: One-way ANOVA indicated that group differences in parent-child interactions neared the significance threshold, with small effect size F (2.83) = 2.971, p = 0.057, ε² = 0.155.

Conclusions: Changes in parent-child interaction quality may take time to develop following injury and may not be apparent by 10 days post-injury. Alternately, the current study may lack the statistical power to identify subtle changes that are beginning to emerge at this stage. Future work should seek to increase the sample size further and to explore associations with post-concussive symptoms.

Introduction: Many individuals living with traumatic brain injury (TBI) must cope with permanent sequelae and rely on close family members for support in managing their new disabilities. Taking on the role of caregiver may involve numerous evolving needs, which if unmet, can significantly impact their lives. Although some resources are available, most are not specifically tailored to the challenges faced by those caring for individuals with TBI (TBI caregivers) and interventions are not always based on robust scientific evidence. Moreover, the greatest effective and acceptable ways to address the needs of TBI caregivers remain largely unknown.

Objectives: To document and prioritize the needs of TBI caregivers.

Methods: This project used a participatory approach in close collaboration with a community organization directly offering services to TBI individuals and their caregivers. A systematic review including quantitative, qualitative and mixed-methods studies, was completed to document the specific needs of this population. The research questions were developed through discussions with stakeholders from the partnering organization. Medline, CINAHL, PsycINFO and Web of Science were consulted. The methodology proposed by the Joanna Briggs Institute was followed, and the Family Needs Questionnaire guided the data extraction and analysis. The findings from this review informed the subsequent phase, which employed the Technique de Recherche d’Informations par Animation d’un Groupe Expert (TRIAGE). This method combines individual and group phases, focusing on building a consensus around prioritizing the most urgent needs. In October 2024, two consensus groups, comprising caregivers (n=8) and community workers (n=8), will be held, with data analysis occurring concurrently.

Preliminary Results: A total of 25 articles were included in the systematic review. The review uncovered a range of diverse needs, reinforcing the necessity of the prioritization phase. Key findings highlighted the critical need for information about TBI prognosis, expected recovery, the rehabilitation process, and potential future impacts. Additionally, the need for peer support, financial assistance, and trustworthy respite care were also identified as major concerns.

Conclusions: Based on the prioritized needs, co-development workshops will be organized to create a tailored program that effectively addresses those needs. This project generates new knowledge to promote best practices in supporting TBI caregivers.

Integrated assistive technology (AT) has significant potential to effectively compensate for impairments in executive function commonly observed after severe acquired brain injury (sABI) such as prospective memory, initiation, planning and sequencing everyday activities. Single-case experimental designs (SCEDs) are an effective means to evaluate tailored AT solutions. The great majority of SCEDs published within the field to date are however of low methodological quality, and there is a need for more rigorous studies. We aimed to evaluate the effectiveness of mainstream technologies (e.g., home hubs, sensors and smart lighting) in tailoring AT solutions to achieving participation goals to enhance client independence in everyday activities after sABI. A series of withdrawal A1-B1-A2-B2 designs was used. Each SCED was planned applying a published a priori study protocol and using the Risk of Bias in N-of-1 Trials to maximise internal and external validity. Inclusion criteria included aged over 18 years, impairments in executive function after sABI, and living in the community with substantial support needs. Seven clients consented to undertake the intervention, with four participants completing the trials. Person-centred goal-directed planning with participants identified diverse primary targets to increase independence in (i) taking medication, AA; (ii) reading an audiobook, BB; (iii) scrapbooking a photo collection, CC; and (iv) preparing breakfast, DD. In each case, a range of potential technologies was explored in consultation with the participants and their family supports, before settling upon the preferred configuration. The list of technologies finally employed included a home-hub, smart speakers, motion and/or contact sensors, smart lighting, and a sleep analyser pressure pad/smart watch. Specific AT configurations varied in each trial. In three of the four trials, results of the weighted average Tau-U across the phases was significant (AA, Tau-U=1.0, p=0.000, z=4.73; BB, Tau-U= 0.55, p=0.0382, z=2.07; CC, Tau-U= 0.62, p=0.0188, z=2.36), indicating increased independence in the targeted goal. In conclusion, this trial has provided evidence that integrated AT solutions linked to activity goals require targeted planning and pilot testing but are feasible to implement in community environments with people with sABI.

Since the Concussion Clinic at GF Strong Rehab Centre in Vancouver strongly recommended that I take up mindfulness after sustaining a brain injury in a car accident in 2013, the original working hypothesis of this decade-long research project was that mindfulness would be beneficial for brain injury. As corroborated by the growing body of research in this field, many aspects of mindfulness did indeed help reduce the frequency, intensity, and duration of my nervous system dysregulation as well as other symptoms. Since mindfulness was prescribed without a warning label, I was surprised to also discover that many mindfulness practices were actually deeply dysregulating. By combining knowledge of the ways in which brain injury survivors are easily dysregulated, with the fact that many mindfulness practices require intimate interoceptive attention to our bodies, I began to understand the logic behind the body's tendency to trigger fight, flight, or freeze responses in reaction to certain mindfulness practices. Research for this qualitative study involved integrating insights from brain injury and mindfulness literature with extensive formal and informal mindfulness training via retreats, courses, and daily mindfulness practice. Initially, I closely tracked the impact of various mindfulness practices on my own nervous system, tacking towards nervous-system regulating practices and away from dysregulating ones. These initial findings were further tested by observing how my mindfulness students responded to modified mindfulness teachings which focus first on regulating the nervous system. The preliminary findings suggest that when first learning mindfulness for brain injury: 1. It is important to give options since everybody and every body is different. 2. It is important to begin with anchors of attention that are least likely to be dysregulating, such as mindfulness in nature, mindful self-compassion, yin and restorative yoga, long slow deep breathing, and joy and gratitude practices. 3. It is important to avoid mindfulness practices which may be more likely to be dysregulating, such as the deep interoceptive awareness of body scans, open awareness meditation, and noting practices, all of which may also be overly cognitive and may incur a detrimental switch cost. 4. It is important to avoid practices that are lengthy, involve multitasking, or that ask students to become comfortable with the uncomfortable sensations of their symptoms before they have some capacity for self-regulation. A logical next step would be to investigate these initial findings further with a large study that compares the efficacy of the Mindfulness-Based Stress Reduction program to the Mindful Concussion course that integrates modifications specifically tailored for brain injury. These findings may encourage brain injury specialists to prescribe mindfulness, but with a much-needed warning label, so that survivors may benefit from the power of mindfulness for brain injury, without falling prey to potential perils.

Background: The King-Devick Test (KDT) is recommended for sideline assessment of sports-related concussions because it is simple and quick to administer. However, the sideline environment and test administration procedure can be variable and may differ based on factors such as the testing platform, administrator training, testing conditions, and timing. Importantly, these factors may be a source of variability and potentially influence KDT scores.

Purpose: Through a systematic review and meta-analysis, we sought to quantify whether and how these factors are a source of variability for KDT scores.

Study Design: Systematic review and meta-analysis.

Methods: We conducted a literature search using the Ovid-MEDLINE and PubMed databases to identify studies published in English between January 2010 and May 2024 that used the KDT for concussion assessment. Subgroup analyses were performed to assess the impact of testing platform, administrator experience, and environmental factors on KDT results.

Results: Out of 248 studies, 56 were included in the final analysis. The pooled baseline KDT score was 45.61 seconds (s) (I2 = 99.53%, p < 0.001). Postseason mean KDT was faster than baseline 42.98 s (I2 = 99.11%, p < 0.001), indicating practice effects. When KDT was administered using both electronic and card platforms, the mean pooled KDT score was faster (41.38 s) compared to using only the cards (44.58 s) or electronic platforms (45.27 s), suggesting that platform choice can influence results. Studies reporting KDT administered by a single assessor achieved a faster mean score than those administered by professional health care providers (41.58 vs 46.56 s), highlighting the influence of test administrators. Subgroup analysis revealed that heterogeneity (I2) remained high ranging from 87.29% to 99.68% indicating multiple and unidentified factors influenced the KDT scores. There were commonalities and differences related to age and gender of players, level of sports, test platform used, administrator, testing environment, and timing of measurements. Age as a moderator showed a significant influence on baseline KDT score with KDT scores improving (indicating faster performance) as age increased, suggesting the need for age-specific normative data. Gender, level of sports participation and environment had minimal influence on the test scores.

Conclusion: The KDT is a useful sideline screening tool for concussion evaluation. However, the accuracy and validity of KDT is influenced by inherent factors such as practice effects, administrator experience, and testing platforms type. Incorporating objective measurements such as eye tracking and establishing standardised training protocols may be valuable in reducing the subjective influence of both test takers and administrators on the test results.

On June 18, 2024, Anne, like thousands of others around the world, experienced a stroke. Her life was instantly and dramatically altered, but one constant remained: her unwavering passion for art. In the hospital, Anne engaged in speech, occupational and physical therapies to address the impairments that now defined her daily life. Despite her progress, she required further rehabilitation and could not return home immediately. This led her to CONNECT Communities in Hamilton, Ontario, a residential program that offers a different approach to recovery.
CONNECT Communities, with locations in Ontario and British Columbia, Canada, is a rehabilitation program that has been operational for over 30 years. It is grounded in the Life Redesign Model of Rehabilitation, which focuses on maximizing neuroplasticity by centering all services around what the person, like Anne, wants to achieve in life. This model employs a coaching approach rather than a traditional therapist model, with multiple daily opportunities to practice meaningful tasks in environments that closely resembled her own, allowing her to integrate new skills naturally in real-life activities that contrasted the typical once-a-week therapy sessions she had experienced. For Anne, this meant her rehabilitation journey was driven by her desire to return to her home and her passion for art. The literature on rehabilitation suggests that this contextually based approach leads to better generalization of skills, enhancing long-term outcomes beyond the clinical environment.
While grounded in best practice, implementing an interprofessional, participation-focused program like Life Redesign presents specific challenges, such as clearly delineating each team member's role while maintaining a cohesive and integrated approach. Without precise definitions of each professional's contributions, it can be challenging for individuals like Anne and their families to fully appreciate the value of the interventions provided. Moreover, identifying and specifying the unique components of this participation-focused approach is essential for research and replication.
To address these challenges, the Rehabilitation Treatment Specification System (RTSS) was utilized. By including Anne’s Life Redesign Goals, identifying specific AIMS and TARGETS, and identifying the necessary INGREDIENTS, it meant that not only did everyone involved have a map, but they also had a clear destination. Using this framework not only supported Anne in her journey back to her art but also ensured that the interventions were clear, replicable, and researchable.
This presentation will delve into the Life Redesign Model and demonstrate how the RTSS can be used to specify clinical interventions within an integrated team. With Anne as part of the team and sharing her story, we demonstrate how by focusing on what individuals want more of in life—such as her return to the canvas—it can drive effective and meaningful rehabilitation outcomes.

Individuals living with the effects of Acquired Brain Injury frequently describe their experiences as 'isolating,' 'confusing,' 'frustrating,' and 'exhausting.' Rehabilitation aims to alleviate this suffering through structured, goal-oriented interventions. Best practice emphasizes that those interventions should be grounded in the everyday contexts of a person’s daily life. Likewise, for decades, rehabilitation literature has consistently recommended that outcomes are maximized when interventions are implemented within real-world environments by engaging individuals in meaningful activities aligned with their personal aspirations and social roles. However, what remains insufficiently addressed is how to translate these personal goals into targeted rehabilitation programs. Without this information, clinicians often return to traditional rehabilitation interventions that focus on impairment-driven outcomes without explicit alignment with the individual’s broader goals. The Life Redesign Model of Rehabilitation is an exception, as this model explicitly puts the individual’s personal goals at the center of all rehabilitation activities. The Life Redesign Model is the foundation of CONNECT Communities, a participation-focused rehabilitation facility located in both Ontario and British Columbia Canada. At CONNECT Communities, people are supported in their recovery by prioritizing what an individual seeks to achieve in their life post-injury and building rehabilitation programming into that. The in-house, interdisciplinary team, comprised of regulated and unregulated professionals, employs a coaching approach to support residents during meaningful, real-world activities. Through close collaboration among staff, families and most importantly the individual themselves, a Life Redesign Plan is developed and is central to this model and the rehabilitation. One challenge inherent in such a plan is that real-life is complex and transcends traditional therapeutic environments. As the rehabilitation offered at CONNECT Community is integrated and interdisciplinary, so to address the real-life needs of the people being supported on their rehabilitation journey, it is necessary to have a clear path. To aid in the development of plans that have both the necessary specifications for effective rehabilitation and maintain the spirit of Life Redesign, CONNECT Communities has embraced the use of the Rehabilitation Treatment Specification System (RTSS). The RTSS is a conceptual framework that allows clinicians to describe and categorize treatments. Using the RTSS Framework to organize, specify and describe Life Redesign Plans, CONNECT Communities is able to better analyze the interventions and help people understand the complexities of rehabilitation and participate. This presentation will share the outcomes of a study designed to analyze the common themes, including aims, targets and necessary ingredients that make up the Life Redesign Plans of a preliminary set of people residing at CONNECT Communities located in Hamilton, ON. By incorporating the use of the RTSS into Life Redesign Plans, it is possible to help people turn the negative experiences of life after brain injury into experiences that now include joy, fulfillment and meaning.

Background: Peer support has been recognized as a promising intervention for people with traumatic brain injury (TBI). Peer support has shown to increase feelings of community, positive mood, and acceptance of their injury for people with TBI. Although there is a quantitative understanding of the benefits of peer support after TBI, there is little known about how meaningful connections are created during peer support intervention. AIMS: This study aimed to 1) characterize how meaningful connections are developed through peer support; and 2) identify barriers and facilitators of creating meaningful connections through peer support.

Methods: Qualitative data were collected through semi-structured interviews and analyzed using constructivist grounded theory. We recruited three groups of participants: (1) adult participants with recent TBI < 6 months to receive peer support; (2) participants who experienced a brain injury > 2 years prior to serve as peer support workers; and (3) community partners to be involved in the implementation of peer support (e.g., participant matching, recruitment).

Results: Nine participants were included in our study: three people receiving peer support, two peer support workers, and four community partners. Data analysis identified four themes that described the experiences of meaningful connections and barriers and facilitators of these connections. First, ‘sharing experiences of brain injury’ explored the importance of having experiences after a TBI understood and validated. Second, ‘relating within a similar place’ highlighted the value of insights on navigating milestones and life events. Third, ‘expanding meaningful conversations’ indicated participants’ desire to connect on personal topics other than TBI. Last, ‘co-occurring growth’ identified how reciprocal learning occurs between both the peer support receiver and worker.

Conclusions: Findings from this study can help future peer support programs to facilitate meaningful connections, and therefore, improve the experience and outcomes of peer support.

Traumatic brain injury (TBI) can result in long-term sequelae, even years after injury. In other chronic disabling conditions, pursuit of complementary and alternative medicine (CAM) is common, as patients pursue treatment options for persistent symptoms that interventions within the traditional medical system have not fully resolved. Preliminary studies investigating CAM adoption in adults with TBI suggest that a substantial proportion of patients pursue at least some CAM in addition to traditional rehabilitation. Here, we investigate how individual differences in healthcare utilization preferences relate to a person’s willingness to pursue various rehabilitation treatment options. In the healthcare decision-making literature, individual differences in healthcare utilization preferences are predictive of both hypothetical and real-world treatment decisions. We define healthcare utilization preference as a person’s preference for pursuing more versus less healthcare. The Medical Maximizing-Minimizing Scale is a valid and reliable individual difference measure for assessing healthcare utilization preference. As measured by the MMS, medical “Maximizers” prefer to receive more health care (e.g. more medical testing, more aggressive treatment) while medical “Minimizers” tend to prefer to receive less health care. In the current study, we test whether Maximizing and Minimizing preferences as measured by the MMS predict treatment preferences in the general population for rehabilitation options across two conditions: evidence-based (EB; operationally defined as those recommended by INCOG with Level A evidence) and non-evidence-based (non-EB; real-world interventions that are either untested or are not currently recommended by INCOG). We will also conduct exploratory analyses to determine whether a history of head injury impacts these hypothetical treatment decisions. METHODS: Participants completed a treatment decision-making task, in which they rated their willingness to pursue various EB and non-EB interventions for TBI-related cognitive impairments. Following this decision-making task, participants completed the MMS scale, which was used to characterize their healthcare utilization preferences (Minimizer vs. Maximizer). Participants answered several questions soliciting their prior history of head injury/concussion/TBI. Participants also completed several additional scales that serve as control variables (health risk tolerance, health status, demographic factors). Stimulus items for EB cognitive interventions recommended by INCOG were modified from treatment descriptions drawn from textbooks and primary journal articles. Stimulus items for non-EB cognitive interventions were modified from treatment descriptions drawn from patient-facing, real-world CAM clinic websites. RESULTS: 276 individuals enrolled in the study, ranging in age from 18 to 87 (M = 52, SD = 17). A substantial proportion (44%) of participants endorsed a history of head injury (TBI/concussion). Analyses of the treatment decision-making data are underway and will be completed by the time of the conference. This study represents the first step in a line of work that will characterize heterogeneity in patient preferences related to healthcare utilization in service of better tailoring patient education to individual clients.

Choosing appropriate outcome measures is a critical step in assessing the efficacy of treatments in intervention research and in measuring clinical progress. In some cases, frequently utilized outcome measurement tools do not adequately capture domains in which key stakeholders are expecting to see improvement. Mismatches between what is measured in research and in the clinic, and what stakeholders expect to improve following rehabilitation can lead to reduced overall satisfaction and trust in the healthcare system. As part of a larger study, we sought to characterize what outcomes matter most to key stakeholders in traumatic brain injury (TBI) rehabilitation. In this presentation we present data elicited from care partners of people with a history of moderate-severe TBI. Fifty-one care partners in the United States completed a two-part survey which included 1) questions to characterize each care partner’s relationship to an individual with moderate-severe TBI and to describe the extent of their caregiving involvement following their loved one’s injury and 2) open-ended questions that were specifically designed to elicit measurable rehabilitation outcome domains. Open-ended responses will be analyzed with qualitative thematic analysis. Twenty-two of the fifty-one care partners (43%) identified as a spouse or significant other of an individual with moderate-severe TBI, followed by a relative (35%), close friend (6%), or child (6%). Thematic analysis of the open-ended responses is ongoing. In a first round of thematic coding, initial codes have been generated. We expect to have organized these initial codes into themes and sub-themes by the time of the conference. Preliminary results from the first round of coding suggest that a large proportion (> 70%) of caregivers expected to see improvements in physical ability, memory, and overall communication. In addition, two thirds of care partners endorsed emotional challenges that they hoped to see improvement on during TBI rehabilitation. Finally, an overall sentiment shared by more than eighty percent of care partners was an expectation or wish for their loved one to ‘return to baseline’, which included comparisons to their life before or a reference to “normal”. Care partners bring a unique perspective on what matters most after brain injury. Future work will synthesize the perspectives of multiple stakeholder groups to inform the development of new outcome measures in TBI rehabilitation.

Background: Repetitive head impacts have long-lasting negative effects on the cognition of athletes. For example, repetitive head impacts accumulated by adult professional soccer players throughout their careers result in long-term negative consequences on cognition. However, the effects of one season of play on youth soccer players are not known.

Purpose: The purpose of this study was to quantify head impact exposure in youth elite soccer and to examine the effects of repetitive head impacts on the cognitive function of youth male soccer players.

Methods: A prospective cohort study of a single boys’ soccer team of 18 players was completed throughout a single soccer season. Head impact frequency data were recorded and video-verified using impact monitoring mouthguards worn during practices and games. Cognitive function was assessed using cognitive-motor integration tasks conducted before the first season game, every subsequent four weeks, and after the last game of the season. The cognitive motor integration task outcome measures included peak path velocity, absolute error, reaction time, full path movement time, and the number of direction reversals.

Results: Over a single soccer season, a total of 1089 head impacts occurred. More head impacts were experienced in practices (n = 683, 62.7%) than in games (n = 406, 37.3%). Midfielders experienced the most head impacts during practices (n = 366, 53.6% of practice impacts), and defenders experienced the most head impacts during games (n = 194, 47.8% of game impacts). Repetitive head impact exposure by position was associated with significant decreases in absolute error of 0.55 mm in defenders (4.92% decrease from baseline, 95% CI [-0.93, 4.9x10-3 mm], p<0.001), peak velocity of 0.46 mm/s in forwards (12.3% decrease from baseline, 95% CI [-0.69, -0.19 mm/s], p<0.001), and a significant increase in reaction time in defenders of 7.03 ms (50.0% increase from baseline, 95% CI [3.30, 9.8 ms] p<0.001).

Significance: Repetitive head impacts within a single soccer season result in a significant decrease in absolute error and peak velocity and slowing of reaction time, indicating a decline in some aspects of youth soccer players’ cognitive function. Deficits in reaction time seen in a single youth soccer season are larger than those observed in other adult sports which highlights that youths may be more vulnerable than adults. Coaches should aim to reduce the number of head impacts experienced by youth soccer players, especially during practices by adjusting coaching styles and practice structure. Future work should target understanding the lasting effects of repetitive head impacts on the cognitive functioning of youth soccer players and examine the effect sex, age, and level of competition have on repetitive head impacts and cognitive function.

Purposes and Hypothesis: Concussions can cause significant emotional distress in the initial phase of injury, including elevated symptoms of anxiety and depression. However, it is unclear to what extent these symptoms reflect dysfunction in neural circuitry caused by concussive injury and to what extent they reflect normal psychological response to the injury event. This study used blood-oxygen-level-dependent functional magnetic resonance imaging (BOLD fMRI) to investigate whether concussion was associated with an abnormal relationship between distress symptoms and brain function.

Methods: A total of 182 varsity athletes, 55 acutely concussed and 127 non-concussed from a single university, underwent eye-closed resting-state functional MRI scans and completed the Hospital Anxiety and Depression Scale (HADS). HADS depression and anxiety sub-scores were compared between the groups. For brain regions previously implicated in depression and anxiety, multiple linear regression assessed the effects of concussion status, HADS score and their interaction on seed-based functional connectivity.

Results: The concussed group demonstrated significantly elevated symptoms of depression (mean difference ± SE: 1.00 ± 0.186; p <.001, CI = 95%) but not anxiety (mean difference ± SE: 0.353 ± 0.265; p=.184, CI = 95%)compared to non-concussed athletes. Examining imaging data, however, there was an interaction effect of concussion and HADS anxiety score (t(176) = 5.528; mean difference ± SE: 0.013 ± 0.002); higher anxiety for concussed athletes was associated with a more extreme increase in amygdala connectivity compared to controls. Conversely, depression scores were associated with reduced sub-genual anterior cingulate cortex (sgACC) severity, (t(176) = -5.281; mean difference ± SE: -0.015 ± 0.003) but this relationship was not affected by concussion status. (t(176) = -4.206; mean difference ± SE: -0.053 ± 0.013).

Conclusions: Our findings provide new insights into network-level changes that occur acutely following concussion. More specifically, symptoms of post-concussion anxiety (but not depression) may have a distinct representation in the brain compared to uninjured controls, suggesting this component of the emotional response may be at least partially caused by the injury. These results provide new insights into the neural substrates of post-concussion symptoms and, translationally, may indicate a novel target for future post-concussion interventions and rehabilitation.

Managing individuals who have sustained either traumatic or non-traumatic brain injury is often challenging for primary care providers and neurological rehabilitation specialists. To our knowledge, a formal and agreed upon standard of practice to evaluate and/or manage the complex needs of brain injury individuals and how those needs may dynamically change over time does not exist. As part of the BeHEALTHY¹ initiative, this feasibility project aligns with the goals of advancing a chronic disease management model for individuals with brain injury, their caregivers and health care providers. Following a systematic literature review, a BeHEALTHY working task force developed an easy to administer holistic and comprehensive intake tool for clinicians to utilize regardless of their specialty when managing the sequelae of chronic brain injury. Key concepts incorporated into the tool include the following 4 components. 1. A shared responsibility among the patient/family/caregivers and health care professionals emphasizing self-advocacy. 2. Promoting proactive and goal-oriented management plans aimed at meeting the dynamic and individualized needs of patients, families, and caregivers over their lifespan. 3. Emphasize collecting relevant pre-injury and post injury medical and psychosocial history including mental health. 4. Emphasize the importance of evaluating an individual’s functional abilities including but not limited to their sensorimotor, neurocognitive, behavioral, social, and community needs. This presentation will review the key core components to an in-person examination of an individual with the sequalae of Chronic Brain Injury. Quantitative validated measures for problem specific somatic, cognitive, neurobehavioral, emotional, and global functioning that can be utilized in a clinic setting will be presented. This personalized and “targeted functional exam” will provide a framework for clinicians to formulate a more specific brain injury diagnosis that leads to a more personalized comprehensive integrated management plan.

BeHEALTHY Chronic Disease Management for Traumatic Brain Injury. A collaboration led by IU School of Medicine with 15 other Traumatic Brain Injury Model Systems centers and the Tampa VA Model System. This project is federally funded in part by the Department of Health and Human Services, Administration for Community Living, National Institute on Disability Independent Living and Rehabilitation Research (grant #90DPHF0006-01-00).

Objective: The purpose of this systematic review was to conduct a comprehensive examination of the evidence, including grey literature, case studies, on the effect of yoga for individuals with acquired brain injury (ABI).

Methods: We conducted the study according to the Preferred Reporting Item for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
Search Strategy: A librarian specializing in health science databases conducted the systematic literature in eight databases in Nov. 2021. An updated search was performed again in July 2023. The search terms were constructed with two concepts: “brain injury” and “yoga” using various keywords and index terms. Study inclusion criteria included 1) participants who were diagnosed with ABI, 2) yoga was used as an intervention or part of interventions; and 3) primary studies.
Two reviewers independently screened the title and abstract of each study for its eligibility and met to reconcile discrepancies. If two reviewers could not reach a consensus, a third reviewer was consulted. A similar process was utilized for full text review, data extraction and risk of bias (RoB) assessment. We adopted the Down and Black Risk of Bias assessment to appraise the studies.

Data Synthesis: We screened 6,209 titles and abstracts and then reviewed 114 studies in full text. A total of 28 studies met the inclusion criteria and went on to data extraction and risk of bias assessment. The most common study design was quasi-experimental one group pre-posttest designs (n=10), followed by randomized control trials (n=8). Fifteen studies (54%) examined yoga in stroke populations, eight studies (29%) examined yoga in traumatic brain injury (TBI), four studies used a mixed ABI sample, and one study focused on people with pituitary adenoma. The number of enrolled participants ranged from 2 to 705 with only four studies enrolling more than 50 participants. Only one study applied yoga in the acute stage in an inpatient setting. Duration of the yoga classes ranged from 6 weeks to 36 weeks; 15 studies (54%) ran yoga classes for 8 weeks.
Reviewing studies that assessed motor functioning (n=9) and studies that assessed cognition (n=8), we found substantial evidence of yoga in improving outcomes such as gait speed and muscle strength, and cognition in people with ABI. Some evidence indicated that yoga might be beneficial for improving overall quality of life, general wellbeing and depression. For balance, occupation, anxiety, pain and sleep, the evidence of the benefit of yoga was weak.

Conclusion: Twenty-seven studies reported positive outcome on at least one of the measures used in the studies. While yoga interventions seem to be promising in individuals with ABI in motor functioning and cognition, the low RoB scores on the 25 studies indicated that the quality of the studies showed the need for improvement.

Background: Both the Consensus Statement for Concussion in Sport Group and the National Athletic Trainers’ Association position statement for concussion management recommend a graduated progression for return to sport and academic activities after concussion. A recent study provided first evidence that recovery following sport-related concussion is affected by the sequence in which collegiate student-athletes advance through stages of the consensus-recommended return-to-play (RTP) protocol. Also recently, an update to that protocol recommends initiating exercise before symptom resolution. We investigated recovery profiles in varsity student-athletes to identify common sequences and whether profiles are differently associated with recovery timelines.

Methods: In the Ivy League-Big Ten Epidemiology of Concussion Study, a multisite prospective cohort study, we identified the order of 1) symptom resolution and initiating 2) exertional activities and 3) academic activities after concussion onset in each athlete. For each sequence identified, we determined its frequency and, using Kaplan-Meier curves, the median days to complete RTP recovery.

Results: We identified 13 sequences of recovery in 2,640 student athletes with sport and non-sport related concussions. The median RTP was 14 days and medians ranged from 10 to 19 days depending on the sequence. The most common sequences included academics < symptom resolution < exertional activities (28%) and academics < symptom resolution = exertional activities (24%) which had median RTP of 17 and 14 days, respectively. Shorter median RTP of 12 occurred when symptom resolution = academics < exertional activities (11%), and 13 occurred when symptom resolution = exertional activities < academics (7%). Longer median RTP of 17 occurred when academics < symptom resolution < exertional activities (28%), and 19 occurred when academics < exertional activities < symptom resolution (8%).

Discussion: Notably, these findings suggest student-athletes with sport and non-sport related concussion mechanisms progressions through stages of RTP protocol are not uniform. Furthermore, recovery profiles varied considerably in median days to the final RTP outcome. Student-athletes and sports medicine teams may progress through RTP protocols based on many factors including symptom severity, personal health history, and prioritize clinical management decisions to return to academics and sports. These factors, and our findings, highlight the need to tailor concussion management approaches to ensure concussion recovery is neither rushed or delayed unnecessarily and student-athletes and concussion management teams should balance the safe and efficient return to sport and academics.

TBI is associated with decreased levels of consciousness, memory impairments, and alterations in the mental state such as confusion and disorientation. TBI can be particularly challenging due to the possible presence of posttraumatic agitation, which manifests as irritability, anger, verbal and/or physical aggression. To manage agitation, different pharmacological agents are used with limited evidence to support their efficacy and safety. In 2019, we published a systematic review assessing the efficacy and safety of pharmacological agents to manage agitation following TBI. The review failed to recommend any agent. In light of newly published research, the purpose of this systematic review was to update the review.

Methods: We included randomized controlled, quasi-experimental, and observational studies with a majority (>50%) of TBI patients (CRD42016033140). Case reports, case series, and observational studies with no control groups were excluded. All population types, from children to adults, that were either in the early stages of TBI recovery or in rehabilitation were included. To update the review from 2019, EMBASE and MedLine were searched for abstracts and articles published between Dec 10th 2018 and May 2nd 2024. In addition, references of identified article were screened for additional articles. Two reviewers screened the titles and abstracts independently for eligible publications. The eligibility of each retained study was evaluated by reviewing the full text. Disagreements of eligibility were resolved by a third reviewer. Two reviewers extracted independently data from all eligible studies using a pre-tested data extraction form. Two reviewers independently evaluated each included study with the Cochrane Collaboration tool for randomised controlled trials and the ROBINS-I tool for observational studies, respectively.

Results: In total, 3477 additional citations were identified from the literature search of which 50 were retained for full-text review. Of the 50 retained, 10 studies were included to update the systematic review. When added to the previous review, a total of 32 studies were identified. Seven of the new studies evaluate the benefit of pharmacological treatments on agitated behaviours as the presenting symptom, increasing the total to 15 studies. In two new studies, agitated behaviours were not the presenting symptom but were measured as a secondary outcome, increasing the total to 11 studies. Lastly, one new study assessed the safety of pharmacological agents used for agitated behaviours after TBI, increasing the total to 5 studies. Six of the seven studies on agitation treatment evaluated the effects of pharmacological agents not described by our initial systematic review including dexmedetomidine, haloperidol, risperidone, phenytoin, levetiracetam, butorphanol and carbamazepine.

Conclusion: Of the new agents, risperidone, carbamazepine, phenytoin, levetiracetam and clonidine failed to show any significant changes in agitation. However, studies using the alpha-2-receptor agonist dexmedetomidine and the cholinesterase inhibitor rivastigmine showed significant decreases in agitation.

Introduction: Individuals who have sustained a moderate to severe traumatic brain injury (TBI) may experience long-lasting challenges that requires informal caregiving from their families. Caregivers often experience high burden due to the substantial life changes that result from the requirements and demands of the caregiver role. Notably, caregivers of individuals with moderate to severe TBI have emphasized their need for emotional rather than practical support. Caregiver peer support is an effective approach to address the emotional needs of caregivers of individuals with other neurological conditions. However, there is limited research on the impact of peer support for caregivers of individuals with moderate to severe TBI.

Objectives: To understand the impact of peer support for informal caregivers of individuals with moderate to severe TBI.

Method: This scoping review was conducted in line with Arksey and O’Malley’s framework. The following five stages of this framework were applied: determining the research question, identifying and then selecting relevant studies, mapping the data, and presenting the results. Studies were included if participants of any relational role were adult caregivers of an adult with a moderate to severe TBI, if the intervention entailed peer support from caregivers with lived experience, and if the impact of peer support on caregivers was described. Systematic or scoping reviews, conference abstracts, and unpublished peer-reviewed works such as dissertations were excluded. Searches were conducted on four electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO), and studies were independently screened for eligibility by two researchers during two stages of review (title and abstract, full-text). Conflicts were resolved through discussions between the two reviewers.

Results: There were 1860 studies that were screened. Of these, 29 were identified for full-text screening, with a total of five studies being included in the review. These five studies had heterogeneous study designs (e.g., randomized controlled trial, pre-post intervention, qualitative). Most caregivers were females, and had relational roles of spouses/significant others or parents of the individual with TBI. Interventions were delivered at rehabilitation hospitals or online, and were a mixture of in-person or online support groups; only one intervention was a one-to-one peer mentoring program. Caregivers reported high burden in areas of personal growth (especially when comparing themselves to their friends), time (including time for self-care), social roles, and emotional and physical support. Overall, caregiver peer support interventions provided emotional support for caregivers of individuals with moderate to severe injuries, however interventions did not demonstrate impact in other areas of burden (e.g., mental health, coping).

Conclusion: Findings demonstrate the impact of caregiver peer support, with potentially enhanced benefit when combined with another intervention to further reduce areas of burden associated with the caregiving role.

Spasticity management is an important part of most Physical Medicine and Rehabilitation and Brain Injury Medicine practices. It is well known that many patients reach the limits of relief achievable through conventional treatments such as medications and chemodenervation, without complete resolution of symptoms. Intrathecal pumps are another treatment option, but not all patients can benefit from this intervention. Given this limitation, further methods for the treatment of spasticity should be investigated. One potential method is the combination of sequentially injected hyaluronidase with or without subsequent botulinum toxin injection. In this literature review, the use of hyaluronidase was explored further, both in combination with other medications and as monotherapy. Hyaluronidase has gained recognition as an adjunct therapy to chemotherapy, enhancing efficacy and bioavailability, while allowing for reduced dosages of the primary medication. Its breakdown of hyaluronan, a component of the extracellular matrix, allows for improved tissue penetration by improving diffusion between cells. Other researchers have sought to benefit from the activity of hyaluronidase with other injectable therapies, leading to the use of hyaluronidase in the treatment of diseases such as Multiple Sclerosis, Rheumatoid Arthritis, and Diabetes. Notably, Goodman et al. demonstrated that the combined use of hyaluronidase and botulinum toxin in treating hyperhidrosis reduced the amount of toxin needed for effective results. The use of hyaluronidase in combination with botulinum toxin is not novel, but its application for spasticity treatment presents a promising opportunity. The accumulation of hyaluronan is a potential factor limiting mobility or range of motion for spastic muscles, especially as individuals age with brain injury. The use of hyaluronidase as monotherapy has been seen in case studies by Rhagavan et al. to lessen spasticity temporarily in individuals with cerebral injury. This literature review has led to the intriguing hypothesis that combining botulinum toxin and hyaluronidase for spasticity management may reduce hyaluronan composition of muscle tissue while enhancing the efficacy of botulinum toxin. Further research is necessary to understand the efficacy of botulinum toxin combined with hyaluronidase compared to botulinum toxin or hyaluronidase alone in patients with a cerebral injury. Researchers could use changes in Heckmatt scale under ultrasound, improvement in Modified Ashworth Scale, or improved degree of range of motion or functional mobility as outcome measures. This study would aim to determine whether the addition of hyaluronidase enhances the therapeutic effects of botulinum toxin, potentially offering a new avenue for treatment in patients who have exhausted other therapeutic options.