Mild traumatic brain injury (mTBI), also known as concussion, is a leading cause of sustained physical, cognitive, emotional, and behavioral deficits. Non-invasive vagus nerve stimulation (nVNS) has been shown to improve cognitive function, reduce inflammation, reduce breakdown of the blood-brain barrier, has neuroprotective effects, and balances the autonomic system. Due to these mechanisms, nVNS has recently been suggested as a potential adjunctive therapy for mTBI.

Methods: Data collection took place at Cherry Creek Neurology from October 2020 to September 2024. Patient selection for use of adjunctive nVNS was based on clinical diagnosis of mTBI (based on history), examination by a neurologist, elevated Neurobehavioral Symptom Inventory (NSI) score and patient willingness to engage in the trial. NSI was completed at baseline (NSI1) and approximately 3 months after starting nVNS (NSI2). Additional surveys to evaluate PTSD, depression, and anxiety were also collected. Patients were concurrently managed with standard of care, taken in context with each individual patient and circumstance. Patients were prescribed nVNS and were instructed to deliver two consecutive stimulations, twice per day. NSI1 and NSI2 scores were compared using the Mann-Whitney Test. Correlation coefficients were measured between NSI scores as well as PTSD, depression, and anxiety health surveys. The effect of injury date on severity of baseline scores and magnitude of change was tested with ANOVA.

Results: 175 patients were evaluated, of which 102 had complete data. The time since injury to the NSI1 baseline ranged from 5 days to 3.5 years. Results showed that adjunctive nVNS significantly reduced NSI scores from baseline in mTBI patients. Twenty-two of 27 NSI components showed significant improvement (p<0.05). NSI components that showed the most significant changes were headache (-0.79, p = 2.1x10-7), concentration (-0.59, p = 0.0002), total NSI score (-9.72, p = 0.0003), and affective score (-3.23, p = 0.0004). NSI components that showed the greatest fractional change from baseline were headache (-23.2%), nausea (-23.0%), total score (-16.4%), dizziness (-15.1%), and depression (-13.8%). Strong negative correlations were measured between NSI1 severity scores and total magnitude of change with the strongest negative correlation found between the initial NSI1 score and change in score for ‘loss of balance’ (r = -0.66). There were notable correlations between the NSI1 score for “depression” and health surveys measuring anxiety (GAD7, r = 0.60) and depression (PHQ9, r= 0.66). Time since injury did not show a significant effect when looking at the total magnitude of change in NSI scores.

Conclusion: When added to standard of care nVNS was associated with reduced symptoms resulting from mild traumatic brain injury including post-traumatic headache, poor concentration, and nausea, regardless of the time since injury to start of treatment.

Fatigue and subjective sleep disturbance are elevated after mild traumatic brain injury (mTBI). This raises the question of whether mTBI-specific factors contribute to the experience of fatigue and subjective sleep disturbance after mTBI. A group of 110 pre-morbidly healthy individuals who had been hospitalised with a traumatic accident approximately 8 weeks prior were examined. Participants were assessed with subjective measures of fatigue and sleep disturbance, psychological distress and pain. Individuals who had suffered a traumatic injury reported significantly greater fatigue and subjective sleep disruption than community-based control participants (n=45). After controlling for pain, psychological status, sex and premorbid level of functioning, those individuals who had suffered a mTBI in addition to their systemic injury (n=64) had equivalent levels of fatigue and subjective sleep disruption as those who had experienced no head injury at time of systemic injury (n=46). Trauma group membership did not significantly predict fatigue or subjective sleep disturbance. In contrast, psychological distress consistently predicted fatigue and subjective sleep disturbance, with pain also inconsistently predicting some fatigue and subjective sleep disturbance variables. This study suggests it is the experience of suffering systemic traumatic injury, rather than mTBI-specific factors, that is associated with elevations in fatigue and subjective sleep disturbance, approximately 8 weeks after injury.

Our department of Rehabilitation medicine deals with patients after brain damage. Spasticity is one of the very common complaints of patients after brain injury, both after stroke and traumatic brain injury(TBI). The application of botulinum toxin is one of the basic therapeutic procedures (1). We have been working according to the concept of Five Step Clinical Assessment (2). Patients are followed up regularly in individual application three- months cycles over several years. In the meantime, they practice on their own according to the instructions and keep a regular diary . We will present the results of our cohort in the years 2021 -2024. Fifty-four patients were followed for at least one year, 11 of them for 3 years. All were aged 18-80 years, and were post stroke or TBI. The earliest application and our follow-up started 3 months after the event. We treat spasticity of the upper limb (UL), lower limb (LL) or both together. In some patients we switch from UL to LL over a period of 3 years. We monitor the changes in spasticity per se (measured by the Tardieu scale), but also functional tests. In the case of UL, we use the Frenchay Arm Test (FAT), which helped in identifying the correct muscles for application, but at the same time we see functional improvement in fine motor skills as well as their better use in ADL. In the lower limb, in addition to the Tardieu scale, we also follow the 10-meter gait test. These measurements are controlled during each visit, before the application, 6 weeks after and three months after the previous application. The majority of patients (84%) improved in most of the monitored parameters within one year (3-4 cycles) not only in the period of the greatest effect of the injection (1-2 months after the injection), but practically never returned to baseline in the severity of spasticity. Patients who were followed for 2 to 3 years still showed improvement in individual parameters in 70 percent. Those who did not improve were examined in more detail, including nerve block, and some were referred for corrective surgery. Our results support the fact that motivated patients who are willing to perform daily home exercises according to the instructions in combination with regular botulinum toxin applications improve in the long term, even three years after the onset of the problem.

References:
1. Chang E, Ghosh N, Yanni D, Lee S, Alexandru D, Mozaffar T. A Review of Spasticity Treatments: Pharmacological and Interventional Approaches. Crit Rev Phys Rehabil Med. 2013;25(1-2):11-22. doi: 10.1615/CritRevPhysRehabilMed.2013007945.
2. Gracies JM, Bayle N, Vinti M, Alkandari S, Vu P, Loche CM, Colas C. Five-step clinical assessment in spastic paresis. Eur J Phys Rehabil Med. 2010 Sep;46(3):411-21.

Background: Anoxic brain injury (ABI) can have a variety of causes with devastating consequences for those that survive the initial insult. Many ABI survivors suffer a subsequent disorder of consciousness (DOC), representing a significant emotional and financial cost for themselves and their caregivers. Much of the literature regarding ABI surrounds cardiac arrest in the hospital setting. However, there is a rising number of drug overdose events occurring outside of hospitals, with fentanyl outpacing all other drugs 1, 2. There is a need for clinicians to investigate and document novel methods of improving functional standards of living within this growing cohort. Zolpidem is a nonbenzodiazepine hypnotic that selectively binds GABA-v1 receptors within the brain, producing effects that can be observed clinically and with imaging. Much of the current body of knowledge represents patients with severe DOC including those with traumatic brain injury. This report details clinically a novel use of zolpidem in an ABI patient with a state of consciousness on the spectrum of DOC consistent with Post Traumatic Confusional State (PTCS) or in this case Post Anoxic Confusional State (PACS).

Case: 38-year-old male with opiate associated outside hospital cardiac arrest causing ABI was admitted to acute inpatient rehabilitation 183 days after his injury at a Rancho VI level. He was dependent in all activities of daily living, with impaired orientation, attention, short-term recall, insight, social pragmatics, inconsistent object use, and unreliable communication. In two weeks of therapies, he remained at a maximum assist level. Thorough workup revealed no organic etiology and he was determined to be in PACS. The patient had no response to amantadine 200 mg daily and made minimal progress for two weeks while in acute inpatient rehabilitation, until zolpidem 5 mg was trialed. This resulted in improved attention, ability to engage verbally, decreased disinhibition, reduced agitation, and meaningful communication and object use. He progressed to supervised Activities of Daily Living (ADL’s) and mobility levels while taking zolpidem with abrupt improvement in Saint Louis University Mental Status Exam (SLUMS) score initial 12, improved to 20/30, Galveston Orientation and Amnesia Test (GOAT) score initial 12, improved to 70, and Supervision Rating Scale (SRS) initially 13 requiring restraints with enclosure bed to a 10 requiring indirect supervision, and Glasgow Outcome Scale Extended (GOSE) 3 to a 4.

Conclusion: After ABI this patient demonstrated signs of a DOC most consistent with the Post Anoxic Confusional State. The patient had little improvement in his functional independence or cognition until zolpidem was introduced, at which point he progressed to a supervision level in ADL’s and mobility and improved across multiple metrics. This case represents a novel use of zolpidem in the Post Anoxic Confusional State, in an individual with fentanyl overdose.

Background: Lower extremity task-specific dystonia is a rare form of focal dystonia characterized by involuntary, sustained muscle contractions that occurs during specific activities, such as walking or stair climbing. Unlike other dystonias, which may present during rest, task-specific dystonia only manifests during the performance of precise, repetitive tasks. The condition can significantly impair mobility and quality of life, as the abnormal muscle contractions disrupt normal motor function. Conventional treatments, including botulinum toxin injections, physical therapy, and nerve blocks, often provide limited relief, necessitating novel therapeutic approaches for more refractory cases. This report presents a case of refractory task-specific dystonia treated successfully with hyper selective neurectomy after multiple failed therapies.

Case: A 56-year-old male presented with left upper extremity tremor and progressive dystonia of the left lower extremity, which began subtly over several years after a prior right caudate nucleus stroke. The dystonia manifested as foot flexion and ankle inversion during ambulation with inability to achieve plantigrade in stance phase during gait. There were no symptoms at rest and physical examination demonstrated normal tone with full active and passive range of motion as well as 4/5 strength in plantar flexion, dorsiflexion, and inversion. Electromyography confirmed left lower extremity dystonia with no upper extremity involvement or cortical myoclonus. With a concurrent diagnosis of parkinsonism, the patient’s left upper extremity tremor responded to Sinemet, but the dystonia did not improve with dopamine therapy. Conventional treatments, including physical therapy, an ankle-foot orthosis, and botulinum toxin injections failed to provide significant relief. Phenol denervation targeting the tibial nerve at the knee and tibial nerve branches within the proximal leg also produced no change in the pattern or severity of the dystonia. Given the lack of response, a multidisciplinary team, including specialists in neurology, physical medicine and rehabilitation, and orthopedic surgery, evaluated the patient, and decided to perform a hyperselective neurectomy. The procedure involved selective denervation of the terminal motor rami within the medial and lateral gastrocnemius, soleus, and posterior tibialis muscles. Postoperatively, the patient demonstrated marked improvement in dystonia, with significant resolution of ankle inversion and toe flexion during walking. The patient’s gait and overall quality of life improved, with no reported adverse effects or motor sensory impairment.

Conclusion: This case is among the first that highlights the potential role of hyperselective neurectomy in treating refractory task-specific lower extremity dystonia. While botulinum toxin injections, phenol nerve blocks and even deep brain stimulator implantation are often used, hyperselective neurectomy offers a targeted surgical solution that preserves motor function. A multidisciplinary approach is critical in such complex cases, providing a path for more personalized treatment options. Further research is needed to evaluate the long-term efficacy of this surgical intervention in Lower extremity task specific dystonia.

Background: Traumatic brain injury (TBI) is an under-recognized public health problem influencing the health trajectories of the homeless population. People with TBI who live in precarious housing situations or experience homelessness often rely heavily on healthcare and community support. Current health and social service approaches have failed to adequately address the unique support requirements of homeless individuals with concurrent TBI to acquire and maintain stable housing. This scoping review aims to better understand the challenges and needs of this population and to recommend ways forward to mitigate these issues.

Methods: A systematic search of electronic databases (MEDLINE, CINAHL, Embase, PsychINFO, and Web of Science) was conducted to identify peer-reviewed articles that met predetermined eligibility criteria. A two-step process was undertaken by two independent reviewers, assessing title/abstract and full articles, respectively, based on inclusion/exclusion criteria, leading to the final 18 articles included in the review.

Results: Of the 18 articles included in the review, 15 studies used quantitative approaches, two used mixed methods, and one employed qualitative methodology. TBI influences various aspects of life in the homeless population, including health status, social lives, and service utilization. Physical issues (e.g., seizures, migraines) and cognitive problems (e.g., attention deficits) are common in this population, and a history of moderate or severe TBI is linked to a significantly higher likelihood of mental health conditions, such as substance abuse and suicide risk. These challenges can lead to poor self-management skills and memory loss, resulting in non-adherence to medication. Furthermore, TBI influences community reintegration, with studies indicating increased odds of incarceration, higher rates of healthcare and social service utilization, and limited access to these services among individuals experiencing both homelessness and TBI. Housing service providers have also reported uncertainty about their knowledge and expertise regarding TBI, reflecting a significant knowledge gap among these providers. To address these challenges and needs, routine TBI screenings in homeless care facilities and improved access to neuro-specific rehabilitation are recommended. These measures, along with considering homelessness risk factors in TBI treatment, could enhance social functioning and prevent future homelessness.

Conclusion: Structured education and training for professionals in healthcare and social organizations working with individuals experiencing homelessness and TBI is necessary to close knowledge gaps and shift attitudes. Moreover, adopting a more holistic and multi-dimensional approach could better support this population and enhance their likelihood of successfully exiting homelessness and improving their overall well-being. This necessitates the delivery of integrated services that combine housing support with services tailored to individual needs.

Outcome after a traumatic brain injury (TBI) is multi-determined and depends on the interaction of factors, including injury severity, pre-injury (e.g. level of education) and post-injury factors (e.g. access to health care resources including neuro-cognitive rehabilitation, but also environmental factors such as family/socio-economic support, follow-up of comorbidity conditions, physical activity, healthy sleep and diet…). Some of post-injury factors are modifiable either as risk or as neuroprotective factors: these factors have an impact on brain health and on post-TBI recovery outcomes. Yet secondary prevention regarding brain health modifiable factors remains insufficient during TBI care management. Because detection and management of risk factors help to prevent neurodegeneration that participate to cognitive decline and clinical dementia, optimizing brain health has gained interest in the neuroscientific community. Multidomain brain health prevention enable indeed protect cerebral reserve and strenghten cognitive reserve that further prevent cognitive decline (FINGER studies, 2021). We describe here the building and assessment of a hospital-based psycho-educational program promoting brain health (i.e., a state of optimal cognitive, sensory, socio-emotional and behavioral functioning, WHO 2022 ) after a severe TBI. The brain health program takes place during the out-patient rehabilitation. It engages firstly a nurse and a rehabilitation physician doctor. Additional rehabilitation professionals can be included when needed (psychologist, occupational therapist) that educate patients about easy steps towards healthy lifestyles. The implementation includes 1) an interview about lifestyles and daily life environment (social support, physical activity, diet, sleep habits), and clinical check/follow-up of comorbidities distinct from the TBI (cardiometabolic/vascular diseases, epilepsia, mood, addictions, sensory loss); 2) a targeted customized psychoeducation regarding modifiable risk factors. This entails recommendations regarding : cognitive stimulation, Mediterranean diet, physical fitness, secondary prevention of TBI (sport accident, road safety), therapeutic observance for chronic comorbidity conditions, healthy sleep habits, the benefits of social interactions, follow-up of mood disorders, prevention of tabacco/drug/excessive alcohol intake. Assessment of a group of patients stress the need for such an awareness program. The present program builds on successful outcomes of MyBrainRobbie, a French-US-Irish program of our group supported from the Global Brain Health Institute. MyBrainRobbie.org is a public health program (launched in 2019) that promotes brain health among children/teens thanks to videos, educational packs and public health outreach strategies (available in 10 languages, free). Visit: http://www.mybrainrobbie.org.

Botulinum Neurotoxin Type A (BoNT-A) injections using Ultrasound (US) guidance have led to research evaluating changes in muscle architecture. Controversy remains as to what constitutes increased Echo-Intensity (EI) in spastic muscles and whether this may affect outcomes. We aim to provide a narrative review of US muscle architecture changes following Central Nervous System (CNS) lesions and explore their relationship to spasticity. Medline, CINAHL, and Embase databases were searched with keywords: ultrasonography, hypertonia, spasticity, fibrosis, and Heckmatt. Three physicians reviewed the results of the search to select relevant papers. Reviews identified in the search were used as a resource to identify additional studies. A total of 68 papers were included. Four themes were identified, including histopathological changes in spastic muscle, effects of BoNT-A on the muscle structure, available US modalities to assess the muscle, and utility of US assessment in clinical spasticity. Histopathological studies revealed atrophic and fibro-fatty changes after CNS lesions. Several papers described BoNT-A injections contributing to those modifications. These changes translated to increased EI. The exact significance of increased muscle EI remains unclear. The Modified Heckmatt Scale (MHS) is a validated tool for grading muscle EI in spasticity. The use of the US may be an important tool to assess muscle architecture changes in spasticity and improve spasticity management. Treatment algorithms may be developed based on the degree of EI. Further research is needed to determine the incidence and impact of these EI changes in spastic muscles.

Background: Individuals with moderate or severe traumatic brain injury (TBI) often experience persistent cognitive difficulties, including impaired self-awareness. Measures of self-awareness typically include structured interviews, clinician ratings, self-proxy discrepancy, and performance-based discrepancy. Virtual reality, increasingly used with individuals with TBI, offers a promising context to assess self-awareness via performance-based discrepancy in tasks that resemble daily life in a controlled environment.

Objectives: This study aimed to (1) compare individuals with moderate-severe TBI and matched healthy controls on self-awareness in a virtual reality multitasking scenario, and (2) to explore associations between self-awareness and age, TBI severity (posttraumatic amnesia duration), and self-reported prospective memory, retrospective memory, and executive functioning within the TBI group.

Methods: The sample included 15 adults with moderate-severe TBI (20% female; mean of 43.5 years; mean of 80 months post-TBI) and 15 matched control participants. Participants completed the Virtual Multitasking Test (VMT), a non-immersive virtual test including three planned tasks (putting away the groceries, preparing a meal using, setting up the table) and several unplanned tasks in a six-room virtual apartment environment. Self-awareness was measured by the performance-based discrepancy score between subjective and objective performance on the VMT. Subjective performance was assessed via a custom questionnaire. Participants also completed the Prospective and Retrospective Memory Questionnaire (PRMQ) and the Dysexecutive Questionnaire (DEX).

Results: For the first objective, the subjective performance of both planned and unplanned tasks in the VMT tended to be rated better than the objective performance by the TBI group as well as the control group, resulting in a higher self-awareness performance-based discrepancy score for both groups. There was no significant between-group difference on this score for planned tasks (p = 0.595, d = .258). However, there was a significant difference on self-awareness for unplanned tasks (p = 0.009, d = 1.045), with the TBI group presenting a higher mean performance-based discrepancy score, indicating a stronger tendency to overestimate their VMT performance than the control group. For the second objective, the self-awareness performance-based discrepancy score did not correlate significantly with age, duration of posttraumatic amnesia, or the PRMQ or DEX scores (ρs < .44; ps > .10).

Conclusions: Using performance-based discrepancy in virtual reality could complement other methods to yield a broader profile of self-awareness after TBI. Future studies should explore whether human-computer interactions and other measures of user experience in virtual reality, such as sense of presence, cognitive load, and engagement, are associated with self-awareness.

Background: Human flourishing is a complex phenomenon, the experience of which has been shown to enhance clinical outcomes and quality of life following traumatic brain injury (TBI). Rehabilitation post-TBI focuses on the functional and mental health outcomes for the patient, however a focus on human flourishing using the PERMA framework developed by Seligman provides a more holistic lens through which to view recovery. PERMA is an acronym for the domains of positive effect, engagement, meaning, relationships, and achievement. We therefore reviewed the literature exploring flourishing in the first two years following TBI to see whether opportunities for intervention exist to improve patient outcomes.

Methods: A systematic review was undertaken of the literature to examine which factors act as facilitators or barriers to flourishing within the first 2 years following TBI. Seligman’s PERMA framework was used to inform the topic of interest using PRISMA. Four databases were searched: CINAHL, Medline, Embase, and PsycINFO. Search terms were resilience, post traumatic growth, adjustment, thriving, identity, personhood, biograph*, storytelling, new normal, narrative, spiritual*, existential, meaning making, transcendence, inner strength, coping, self-concept, hope, or flourishing. These results were combined with the following terms: traumatic brain injury, acquired brain injury, brain injury, head injury, craniocerebral trauma, head injury, brain injury, closed head injury, ABI, or TBI. Extracted data was analysed using content analysis to create a descriptive summary of the results.

Results: The content of 53 studies published between April 1988 and March 2022, were analysed. 63 factors acting as facilitators and 40 factors acting as barriers to human flourishing in the TBI population were identified. The factors were categorised into individual, social and community, and structural groups and the results presented according to the domains of PERMA. The individual facilitators included the maintenance of an ability to self-reflect and maintain a sense of an inner self or identity. Social and community facilitators included a supportive family and healthy partnerships, and structural facilitators included interventions such as art therapy and dignity conserving care. Conversely, barriers to flourishing included individual factors such as a loss of self, social and community factors such as a lack of family support, and structural factors such as a highly regulated inpatient environment.

Conclusion: There are many factors that act as facilitators and barriers to human flourishing in the TBI population within 2 years of injury. Clinical recommendations include assessing the factors influencing human flourishing for the person with TBI to ensure that appropriate interventions and type of patient care are implemented. This would support the patient to have an experience of flourishing despite the functional deficits resulting from the TBI. Future research could focus on the codesign of an intervention in an inpatient rehabilitation setting to enhance human flourishing.

Primary prevention comprises a wide array of strategies to reduce the onset of concussion in contact sport athletes. As such, protective gear, proper sporting techniques, changes to game rule, athlete education and neck strengthening have been pushed forward in the past years in the hope of reducing concussion incidence. It is indeed believed that neck function might play a significant role in athletes engaging in contact sports where repeated head impacts are frequent. If the protective nature of neck function is established, little knowledge exists on the role of repeated head impact on neck function, and how neck function evolves throughout a football season. The aim of this study was 1) to measure repeated head impacts and 2) measure neck function in varsity football athletes throughout a season. A total of 23 university level varsity football athletes (mean age:23±468.12 , mean weight (lbs): 236.29 ± 60,92, mean height (cm) : 185.05±6,20) from the University of Montreal team volunteered to participate in the study. Participants wore instrumented mouthguard collecting head impact data (Prevent biometrics) during a total of 8 regular season and 4 playoff games. In addition, participants engaged in cervical function screening (range of motion (ROM), function, and pain) at three-time points (preseason, midseason, postseason). A cumulative total of 2319 head impacts was recorded amongst participants, with participants sustaining on average 132.75±78.17 (range 32-285) head impacts throughout the season; average impact intensity was of 13.2±8.88 g (range 5-91). When performing a repeated measure ANOVA, no assess changes in neck ROM, significant decreases in extension (from 70.41 to 63.97 (p=0.02)) and left lateral flexion (from 58.65 to 51.15 (p=0.001)) were reported from preseason to postseason. No significant changes in neck function and pain across the 3 time points were reported. Spearman’s rank correlations were computed to assess the strength of relationship between amount of head impact and 1) neck ROM, 2) neck function and, 3) neck pain. No significant associations were found for all variables. Our study showed that university level varsity football athletes exhibit changes in neck ROM across a sporting season. These results suggest that neck ROM may be affected by the physical demands of football, throughout the short, intense season. Although no significant associations were found between changes in neck function and head impact metrics, it was shown that neck ROM varies during the season, and future studies should inquire whether neck ROM variations, as seen in this study, have an effect on primary concussion prevention.

According to data from CEOWORLD which surveyed 110 countries, Taiwan tops the list of best healthcare systems in terms of medical Infrastructure, professionals, medicine availability ,cost, and government readiness. This stellar performance comes with intangible cost, which is the brain drain of medial professionals who work in constant high stress environment, particularly neurosurgeons.
Taiwan National Healthcare Insurance (NHI) system, established in March 1995 by the Government, has provided high-quality health care with low insurance premiums. The average monthly insurance premium the typical Taiwanese citizen pays is NT$1377, which is approximately US$42.
Too much emphasis on low premiums is ambivalent. One one hand, it ensures equitable access for 23 million citizens and around 851 thousand non-citizens who hold valid NHI policy. On the other hand, it results in financial problems for the NHI system, which incentivizes medical facilities to find ways to cut costs. This skewed emphasis on cost-cutting has led to an unappealing work environment, characterized by long working hours and low salaries. The strain on the health-care system is evident in the nurse-to-patient ratio, which averages 1:4 in the States, but is 1:8.6 in Taiwan. Taiwan doctors work longer than their counterparts in other countries, with an average of 59.8 hours per week compared with 49.6 hours per week for similar level physicians in the States. Neurosurgeons are on top of the working hour list. Such a unforgiving work environment considerably affects patient safety and increases burnout for nurses and young doctors.
The number of neurosurgeon is highly regulated based on the number of general population and training center. In the past few years, though the number of board certified neurosurgeon had been stable(21-29 per year), the number of resident who chose neurosurgery has trending down. Some training centers had zero applicant. However, the number of young doctors who practices in esthetic clinic surges. As of 2023, the number of doctors practicing in neurosurgery and esthetics is 689 and 12,000, respectively. One of the explanations for the brain drain is the risk-and-compensation mismatch from NHI payment scheme.
As Taiwan population ages, the brain drain will inevitably worsen. An increasingly ageing society in Taiwan would further exacerbate the NHI financial burden, as previous studies have shown higher healthcare use and societal care costs among the elderly.
Taiwan healthcare system needs an overhaul. One is to raise the insurance premium to reflect the reality of an ageing society and an under-resourced healthcare system. Another change is to adopt reasonable payment scheme for neurosurgeons and other specialists who provide services for critical/complicated patients in order to align with the standards observed in other high-income countries.

Following acquired brain injuries due to different aetiologies (e.g., traumatic, anoxic, ischemic), patients may end up with Disorders of Consciousness (DoC) characterized by disturbances in self- and/or environmental awareness which can persist for up to many years. Improving both diagnostic and prognostic accuracy in DoC patients is one of the main aims of the current clinical and research agenda since it could help in better orienting rehabilitative interventions. However, the instrumental techniques used so far to this aim are costly (e.g., functional magnetic resonance imaging) and require the patients’ transfer into equipped specialized centres most of the time. In overcoming this issue, the use of ultrasound techniques (US) should be considered, since they are inexpensive bedside applicable instruments, and guarantee the acquisition of both brain morphological and blood flow-related information. Unfortunately, experimental data concerning the US application for improving DoC diagnosis are scarce, and their prognostic value has never been explored nowadays. For these reasons, we proposed to adopt the US in both chronic and post-acute DoC patients to search for reliable US measures helping to improve both diagnosis and prognosis. We developed a US acquisition protocol as part of a funded project by the Italian Ministry of Health which has been already adopted on 45 patients with DoC who are currently in follow-up to evaluate the US prognostic value. Moreover, as part of the same project, we planned to use the US as a neuromodulatory technique to boost the DoC level of consciousness. We think that enlarging the knowledge about diagnostic, prognostic, and therapeutic options by adopting feasible and low expensive techniques could be beneficial for patients, families, and national health systems since it can positively affect clinical activities and DoC patients’ management.

Clinical practice guidelines (CGPs) – designed to guide care – tend to overlook equity and disadvantaged groups and instead, focus on the effectiveness or cost-effectiveness of care. As a first step to improving equitable care, a systematic review was conducted to explore how (1) evidence regarding individuals who intersect with the criminal justice system (CJS) is include in CPGs for TBI and evidence regarding TBI is integrated in CPGs for CJS and (2) equity is considered in CPGs for CJS. Electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google search, and reference lists for CPGs for TBI and CPGs for CJS were systematically searched. Fifty-seven CPGs for TBI and six CPGs for CJS were included in this review. Of the CGPs for TBI, 14 included information relevant to the CJS, however, only 1 provided a concrete recommendation to consider legal implications during vocational evaluation in the forensic context. Of the CPGs for CJS, two acknowledged the prevalence of TBI and one specifically recommended considering TBI during health assessments. There was limited consideration for equity in CPGs for CJS. The following recommendations were identified from this review to enhance equity in healthcare for this population: (a) conduct research, including investigating the process of screening for TBI in individuals who are involved with the CJS and (b) use equity assessment tools in guideline development.

Adherence to clinical practice guidelines (CPGs) for traumatic brain injury (TBI) leads to reduced length of stay in the hospital and improved functional outcomes. However, the extent to which equity is considered in these CPGs is unclear. A systematic review was conducted to assess equity in CPGs for TBI and homelessness. Electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs were systematically searched. Fifty-eight CPGs for TBI and two CPGs for homelessness met the predetermined eligibility criteria. Of the CPGs for TBI, 5.2% integrated evidence regarding homelessness. All the CGPs for homelessness integrated evidence regarding TBI, however, they only acknowledged that TBI is prevalent among individuals experiencing homelessness. Equity was rarely considered in the content and development of the CPGs for TBI – disadvantaged populations were seldom involved among members of the working group and no plans to assess and monitor guideline uptake were included. To improve health services and outcomes, the following opportunities were identified: (a) integrate evidence regarding TBI and homelessness in CPGs to develop recommendations that are appropriate and achievable for individuals experiencing homelessness and TBI, (b) engage underserved populations in all stages of the guideline development to ensure that recommendations are supported by their experiences and reflect and address their needs, and (c) conduct and prioritize equity-driven research focused on, and with underserved populations, to address their repeated exclusion in research and to build the evidence base on TBI and homelessness that can contribute to CPGs.

Background: Cognitive deficits are common following moderate-severe traumatic brain injury (TBI). Addressing these deficits is critical for promoting patients’ return to valued life roles. Fortunately, at the group level, a number of cognitive rehabilitation interventions have proven efficacy. Yet, these group-level results obscure the fact that for many interventions, a significant proportion of patients are non-responders. This variability in treatment response underscores the need for personalized approaches to rehabilitation. Critically, the vast majority of interventions for cognitive impairments are behavioral: patients work with a therapist to learn or re-learn some set of knowledge or skills. Therefore, the primary treatment mechanism in cognitive rehabilitation relies heavily on learning and memory. Furthermore, there are multiple human memory systems (e.g. declarative, procedural) supported by distinct neural networks, and individual patients with TBI can differ in their degree of impairment across each system. Similarly, behavioral interventions can differ in the degree to which they rely on declarative versus procedural memory. The current study evaluates the proposal that the memory demands of an intervention approach are a key factor in whether a given intervention “works” for a particular patient. Here, we present preliminary data from an ongoing proof-of-concept study.

Methods: Patients with a history of moderate-severe TBI complete two research visits. During the first visit, a battery of measures assess participants’ declarative and procedural memory, including clinical measures (e.g. Wechsler Memory Scale; Rey Auditory Verbal Learning Test) and experimental measures drawn from the cognitive neuroscience literature (e.g. spatial reconstruction; mirror-reversed reading; rotor pursuit). During the second visit, participants complete two different interventions targeting learning of face-name associations. Importantly, the two approaches differ in the degree of their hypothesized reliance on declarative versus procedural memory. The Visualization condition emphasizes the use of visual imagery strategies to support deep encoding via the declarative memory system, while the Errorless condition emphasizes principles of errorless learning to support acquisition of face-name associations via the procedural memory system. Following training, participants complete tests to evaluate how accurately they have learned the trained face-name associations in each condition. Long-term retention of face-name associations is assessed one week later. In this presentation, we will report preliminary results assessing whether patient memory profiles as measured in the first visit are predictive of differential performance across the two intervention conditions.

Results: To date, nine participants with moderate-severe TBI have been enrolled. Study procedures are feasible and data analysis is ongoing. Preliminary results from at least twenty participants will be presented at the conference. The current study provides an important first step in understanding how a patient’s memory profile impacts their response to behavioral interventions that vary in memory demands, with the long-term goal of improving rehabilitative outcomes for individuals with TBI.

Introduction: Understanding how the brain changes during development is essential to identifying both typical and atypical neurodevelopment. One key challenge in this field is distinguishing between intra-individual variability (changes occurring within the same person over time) and inter-individual variability (differences between individuals). This distinction is particularly important when studying pediatric brain development, where the magnitude of inter-individual differences can overshadow the more subtle intra-individual changes. Our study investigates whether log Jacobian maps derived from brain deformation fields can encode both intra- and inter-individual variability using longitudinal pediatric MRI data.

Methods: We analyzed T1-weighted MRI scans (N = 279 images) of 96 children (46 females) aged 2 to 7 years from the Calgary Preschool Dataset, generating 434 intra-individual pairs (comparing scans of the same child at two different ages) and 433 inter-individual pairs (matching children by initial age, age interval, and sex). These images were registered using the Elastic SyN ANTs algorithm to compute log Jacobian maps, which represent local volume changes in the brain, ranging from -1 (contraction) to 1 (expansion). The log Jacobian maps were used to train a 3D convolutional neural network to classify intra- versus inter-individual changes. Two experimental scenarios were explored: one allowing overlap between the training and test sets for the same subjects, and another with no overlap.

Results: We used 10-fold cross-validation to evaluate both scenarios, finding that the no-overlap scenario yielded slightly higher accuracy and F1 scores. The highest accuracy (0.989) was achieved when inter-individual pairs were matched not only by age but also by sex. The log Jacobian values showed that intra-individual pairs had a broader distribution of local volume changes compared to inter-individual pairs, indicating more pronounced brain morphology shifts within individuals. This finding aligns with the expectation that inter-individual comparisons, involving different subjects, would capture more global deformations rather than localized changes.

Discussion: Our results demonstrate that log Jacobian maps can effectively differentiate between intra- and inter-individual variability in pediatric brain development. This approach has the potential to contribute to modeling typical neurodevelopmental trajectories and detecting deviations that could signal pathology.

Conclusion: Looking forward, we plan to extend this methodology to study mild traumatic brain injury (mTBI) cases from the KOALA study. TBI has been linked to changes in brain morphometry (King et al., 2019), yet there are few studies on children younger than 6 years, where TBI prevalence is higher. This future work will apply our log Jacobian map-based pipeline to pediatric mTBI cases to investigate whether this technique can detect subtle brain changes following injury. Given the growing concern over the long-term effects of mTBI on children’s brain development, particularly in volumetric changes and functioning, this proposed method could provide valuable insights into how mTBI affects neurodevelopmental trajectories.

Traumatic brain injury (TBI) is the most common neurological disorder and poses a significant public health burden, with 60-95% of cases classified as mild traumatic brain injuries (mTBI). While mTBI affects both men and women across all age groups, research has historically focused on men, leading to limited attention on women-specific health concerns. Females experience distinct physiological changes throughout their lives, including fluctuations in endogenous sex hormones and other biological processes not seen in males. These factors may affect their susceptibility to mTBI, recovery, and response to treatment. However, how age and physiological differences uniquely influence mTBI outcomes in females remains poorly understood.
The aim of this study was to examine sex-specific variations in brain network connectivity metrics and assess age-related differences in how these metrics influence recovery outcomes in females following mTBI. Four hundred forty-two adults (151 females) between 18 and 83 years old with Glasgow Coma Scale (GCS) scores 13-15 were included in this analysis. Data were collected as part of the prospective multi-center Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) and downloaded from the open-access Federal Interagency Traumatic Brain Injury Research information system (FITBIR). Functional magnetic resonance imaging (fMRI) was performed within two weeks post-injury. Network connectivity was measured with graph theory-based metrics. Recovery outcomes at 12 months post-injury were assessed throughout the Rivermead Post-Concussion Symptoms Questionnaire (RPQ).
Initial analyses revealed that while clustering coefficient and characteristic path length were not significant, modularity at two weeks is a strong predictor of RPQ at 12 months (β=-10.809, p=0.001) in mTBI. Notably, females showed a stronger association between higher baseline modularity and fewer post-concussion symptoms compared to males (β=8.658, p=0.027). This biological sex difference prompted further focus on females, where age-specific patterns emerged. Younger females (17-34 years) showed a significant association between higher early-stage modularity and better recovery at 12 months (β=-13.625, p=0.002). In contrast, this association was not observed in females aged 35 and older.
While brain network modularity appears to be a key determinant of recovery in younger females, its diminished effect in older females suggests that additional factors, such as hormonal fluctuations throughout the lifespan, may also contribute to recovery outcomes. Nevertheless, these factors have not been collected in the large population cohort studies of TBI. These findings underscore a critical gap in mTBI research, highlighting the urgent need to explore sex-specific and age-related factors, such as hormonal fluctuations, pregnancy, oral contraceptive use, and the impacts of perimenopause and postmenopause. Addressing these factors in future studies will not only fill this gap but also open new avenues for improving our understanding of women's brain health in mTBI.

Aims: To investigate whether children with non-accidental traumatic brain injury will be at higher risk of psychiatric disorders compared to TBI due to accidental causes.

Methods: A case-control study was conducted using data from the Hong Kong electronic medical record. Clinical data of paediatric patients aged 0 to 18 admitted to public hospitals with TBI between January 2005 and December 2019 were extracted from the Hong Kong Clinical Data Analysis and Reporting ,which is a territory-wide database containing clinical data of patients admitted to the public hospitals in Hong Kong. Patients in the sample having records of maltreatment within the same hospital admission episode for TBI were regarded as case subjects, while four control subjects with only TBI diagnosis were matched to each case based on their age, gender and time of admission (i.e. same calendar year and month). The psychiatric disorders of interest were attention deficit/hyperactivity disorder (ADHD), autism spectrum disorder, anxiety disorders, depressive disorders, mood disorders, bipolar disorders, schizophrenia, personality disorders, substance misuse and dependence, and self-harm behaviours. Records of patients’ psychiatric conditions were extracted 90 days from their inpatient admission date to 31 December 2023. χ² test was performed to compare the prevalence of the psychiatric disorders between cases and controls.

Results: A cohort of 870 patients with records of TBI were followed up between 2006 and 2015. There were 174 non-accidental TBI patients and 696 TBI control subjects. Non-accidental TBI patients had higher prevalence of ADHD (8.6% vs 4.5%, p = 0.036), depressive disorders (4.0% vs 1.0%, p = 0.011), mood disorders (2.9% vs 0.3%, p = 0.005), personality disorders (1.7% vs 0.1%, p = 0.027) as well as drug misuse and dependence (1.1% vs 0.0%, p = 0.04).

Conclusions: Children with non-accidental TBI had higher risk of psychiatric disorders than TBI due to accidental causes. Our findings suggest the important interplay between environmental stressors and mental health outcomes.

Objective: This study aims to evaluate the effectiveness of combining repetitive transcranial magnetic stimulation (rTMS) with biomechanical-facilitated motor learning exercises to improve the motor function of children with brain injury.

Methods: This is a double-blind, sham-controlled randomized controlled trial. 10 children with a history of brain injury were randomized to receive 10 days of either sham or active rTMS followed by biomechanical-facilitated motor learning exercises. The primary outcome was assessed using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) on the last day (D10) of the intervention. ANOVA test was applied for data analysis.

Results: 6 subjects were randomized to the intervention group (median age 12.6 years) and 4 were randomized to the control group (median age 13.4 years). At D10, The increase in total motor composite was significantly higher in the treatment group compared to the control group (P=0.031). Significant differences between intervention and control group in total motor proficiency (F=24.666, P=0.001), specifically in balance (F=7.080, P=0.029), running speed and agility (F=12.925, P=0.007), upper limb coordination (F=12.925, P=0.007) and strength domains were observed (F=25.504, p<0.001).

Conclusions: The combination of rTMS and motor learning exercises significantly improved the motor performance of children with brain injury, compared to motor learning exercises alone.

Objective: To compare the psychosocial functioning of children and young people (CYP) with long COVID and associated microstructural brain changes with those without history of COVID.

Methods: This case-control study involved 180 participants between 6 and 24 years old. Participants had MR-Diffusional Kurtosis Imaging (DKI) of the brain. Participants and their parents were invited to complete a survey on emotional & behavioral difficulties, quality of life and level of psychological distress. Univariate ANOVA was conducted to compare the psychosocial functioning and the brain microstructures of participants with long COVID and the control subjects. Multiple regression analyses were conducted to explore the relationships between the brain microstructural changes and the wellbeing among the subjects with long COVID. Regions showing significant differences between cases and controls were selected for the analyses.

Results: Compared to the controls, participants with long COVID had more behavioral and emotional difficulties (F = 9.23, Pcorr = 0.006), with more emotional problems, hyperactivity issues and peer problems. Their overall quality of life was poorer (F = 14.2, Pcorr < 0.001), with worse physical, social, and school functioning. CYP with COVID also reported more psychological distress (F = 5.92, Pcorr = 0.05). Regression analyses on a stratified sample of school-aged children (6 - 11 years) revealed that increased MK values in left dorsolateral superior frontal gyrus were associated with less peer problems (estimate = -26.73, p = 0.047), and increased MK values in left superior frontal gyrus, medial were related to less peer problems (estimate = -26.13, p = 0.034). Among the adolescents aged 12 to 17, increased MK values in the right cingulate gyurs, posterior part were associated with less emotional problems (estimate = -10.90, p = 0.049), and increased FA values in white matter right uncinate fasciculus was related to better prosocial behavior (estimate = 17.22, p = 0.015).

Conclusions: The psychological functioning of children and adolescents with long COVID were impaired. Besides their physical recovery, clinicians should also monitor their mental wellbeing.

Study supported by the RGC GRF grant no. 17600924, Government of the HKSAR

Context: Research on language and pragmatic impairments in right hemisphere brain damage (RHD) is relatively sparse compared to left hemisphere brain damage studies. With 50–80% of individuals experiencing language-pragmatic deficits following a right-sided stroke, addressing this knowledge gap is crucial. This systematic review aims to consolidate existing knowledge and guide future research in this critical area. Focusing on studies published between 1970 and 2024, the review provides a comprehensive overview of half a century of research on RHD-related communication disorders.

Methods: A PRISMA-guided review was conducted, initially identifying over 16,275 papers. After a rigorous double-blinded screening process involving title and abstract reviews 1,255 were discarded followed by 783 after full-text screening articles. Methodological quality evaluation then excluded another 122 articles, leaving 318 for data extraction.

Results: Although data analysis is ongoing at the time of submittal, data-driven preliminary findings reveal several key points. Most studies employed group experimental designs with relatively small sample sizes, focusing on characterizing the linguistic aspects of communication. Notably, only eight studies were interventional in nature. These trends highlight the need for larger-scale studies and more diverse research approaches. Imaging was commonly used for lesion diagnosis, providing valuable insights into the neuroanatomical correlates of communication deficits. Within the predominant focus on linguistics, equal attention was given to production and comprehension. This balanced approach provides a comprehensive view of linguistic deficits in RHD. Notably, paralinguistic and extralinguistic domains were also examined in a considerable number of studies, reflecting a growing recognition of the multifaceted nature of communication disorders in RHD. However, standardized RHD batteries were rarely employed, suggesting a potential gap in comprehensive assessment practices. Nearly half of the studies (47%) did not assess major cognitive domains beyond unilateral neglect. This limited scope of cognitive evaluation may hinder a full understanding of the complex interplay between various cognitive functions and communication abilities in RHD patients.

Conclusions: This ongoing review highlights the evolving nature of research on impairments of language and pragmatics following RHD. The findings reveal both progress and gaps in our understanding of these disorders. The predominance of small-scale studies and the limited use of standardized assessment tools suggest areas for methodological improvement in future research. The review's findings will have significant implications for both research and clinical practice. These insights will contribute to the development of improved assessment and treatment tools for individuals with RHD, potentially leading to more targeted and effective interventions. This comprehensive analysis will not only consolidate our current knowledge but also pave the way for advancements in understanding and treating language and pragmatic deficits in individuals with RHD.

Context: During the state-of-emergency of the COVID-19 pandemic, standards of neurorehabilitation care in intensive rehabilitation facilities (IRFs) were significantly altered. These changes affected the physical environment and care trajectories for patients, families, and healthcare professionals. Designated facilities established isolated "hot zones" for COVID-19 patients while maintaining "cold zones" for routine care. In 2021, a Québec-wide research team initiated a retrospective analysis to document the trajectory and outcomes of rehabilitation care during the initial pandemic waves.

Methods: The study used a mixed methods approach, combining quantitative and qualitative data from designated rehabilitation facilities. The quantitative analysis involved reviewing 993 medical records of patients, focusing on indicators such as Functional Independence Measure (FIM) scores and its Minimal Clinically Important Difference (MCID) scores, length of stay, intervention doses, rehospitalization rates. Qualitative data were collected through consultations with 55 stakeholders. The Post-Acute Care rehabilitation framework integrated findings into key targets for future crisis preparedness.

Results: Regarding clinical outcomes, patients in both "hot" and "cold" zones showed similar functional progress (FIM and MCID p>0.05). However, those infected with COVID-19 experienced longer stays (p<0.001) and received lower intervention doses (p<0.001). Despite lower functional capacity at admission and discharge (p<0.01), the proportion of patients reaching FIM MCID was similar between groups (p=0.37). Nosocomial COVID-19 infections were associated with lower slower progress (p<0.05), and increased rehospitalizations (p<0.05). Regarding the trajectory, qualitative findings revealed that best practices were more disrupted in “hot zones” compared to “cold” ones. Issues related to rehabilitation structures, staffing, facilities, and communication impacted care quality. The prohibition of family visits and physical isolation significantly affected patients' psychological well-being and discharge planning.

Conclusions: The rehabilitation care system demonstrated resilience in adapting to pandemic challenges. Although the quality of care remained sufficient to support functional progress, efficiency was notably compromised for patients with nosocomial infections in designated IRFs. Lived experiences were characterized by social isolation and disruptions in the continuum of care. This comprehensive assessment of care quality and stakeholders' experiences identifies five key areas for improving future health crisis preparedness in neurorehabilitation: valuing families, creating a supportive rehab environment, fostering socialization, ensuring a safe care trajectory, and favoring local management. These findings offer valuable guidance for policymakers and healthcare professionals.

Background: Growing evidence suggests that patients can experience episodes of "disconnected consciousness" (DC; environmental stimulus-independent mental content) during emergency procedures, including near-death experiences (NDEs).

Aims: This project aims to (1) prospectively investigate the prevalence and consequences of DC among patients admitted to the resuscitation room (RR) of our hospital, (2) accurately characterize these DC episodes, and (3) pinpoint their underlying neurobiophysiological processes.

Methods: A total of 201 adult patients who show mild to severe disturbance of consciousness will be included during their RR stay. An audio-visual system will allow for objective environmental control. A wide range of medical parameters will be collected, including partial pressure of carbon dioxide in arterial blood and blood pH. Regional cerebral oxygen levels will be recorded using near-infrared spectroscopy, along with a 6-channel electroencephalogram (EEG). Specifically, EEG data will be divided into time windows and analyzed in the time-frequency domain (using the Continuous Wavelet Transform) and transient changes in brain signal complexity (using Lempel-Ziv Complexity index – LZC) will also be sought. The prevalence and consequences of DC are evaluated through semi-structured interviews (including free narratives, memory tasks, and administration of standardized scales, such as the NDE-Content scale which allows the identification of NDEs using a validated cut-off score) conducted within three days post-admission or awakening (T1), and then at 2 (T2) and 6 months (T3).

Preliminary Results: (1) Out of 29 patients included so far, 23 have survived and 18 have participated in the first interview and 8 in the second interview. Six patients (33%) reported DC episodes. (2) Four of these DC experiences were identified as positive NDEs while two were considered distressing NDEs. One DC was identified at T1 but was not re-identified at T2. Conversely, 2 DC did not meet the sufficient cut-off score at T1 but were identified as DC at T2. (3) We also here present the EEG results for one patient who experienced a negative NDE. We observed increased brain activity in beta and gamma frequency ranges and higher LZC values in two consecutive windows compared to the rest of the recording.

Conclusions: (1) With promising preliminary data, our project aims to identify and study DC episodes in emergency patients. Initially, we expected 10-20% of patients to experience a DC, but our sample shows an incidence of 33%, exceeding expectations. (2) This is the first study to use a prospective longitudinal approach, and our preliminary results suggest that DCs may not be consistently stable over time, challenging current assumptions in the scientific literature. (3) We also hypothesize that transient gamma activity may serve as a neural correlate of DC episode. Ultimately, we aim to increase awareness and understanding of DC within the medical community.

Introduction: Following a traumatic brain injury (TBI), many individuals will require cognitive assistance to complete complex activities, such as meal preparation. Executive dysfunction, which affects the ability to formulate goals, develop plans, execute those plans, and verify whether goals have been adequately attained, is one of the main reasons for needing cognitive assistance. Family caregivers may be called upon to provide this support in everyday activities. Promising solutions, such as assistive technologies for cognition, may also offer personalized assistance while reducing the burden on caregivers. However, while guidelines exist for providing cognitive assistance, little is known about how individuals with TBI perceive the assistance and whether they find it acceptable.

Objective: Document the perceptions of individuals with TBI regarding personalized cognitive assistance provided during a meal preparation task.

Methods: A qualitative descriptive multiple case study was conducted. Five individuals having sustained a moderate to severe TBI at least one year prior were invited to three sessions to explore their perception of personalized cognitive assistance. During session 1, participants were assessed using the IADL Profile, an ecological observation-based tool documenting independence in complex activities, during which cognitive assistance is provided only when necessary. During session 2, a new meal preparation task was selected to challenge each participant based on observed difficulties and assistance needs. Cognitive assistance was offered during this task to help participants achieve their objectives the most by themselves while improving their performance. The last session consisted of an individual interview, during which participants were invited to discuss their perception of the assistance they received using video recordings from the two previous sessions. Interviews were transcribed and analyzed using inductive thematic analysis.

Results: Overall, participants expressed appreciation for the assistance provided during the meal preparation tasks. They highlighted how cognitive assistance helped them better understand the tasks and the steps needed to complete them, follow through efficiently, and remember elements they might have forgotten. While being guided, participants noted that they had time to think and try things on their own, which gave them a sense of independence. However, although they generally approved of the assistance, they felt it could be intrusive, anxiety-provoking, or unhelpful at times. In such situations, they found that explicit assistance was beneficial, emphasizing the need to adjust support based on the individual's emotional response.

Conclusions: This study highlights the acceptability of cognitive assistance for individuals with TBI, as they pinpointed both the need to be guided and structured in the meal preparation task while having the time and space to try and think by themselves. Further studies could document how to optimize assistance based on these needs, and adjust assistance provided by family caregivers and assistive technologies for cognition accordingly.

Background: Principles of neuroplasticity and motor learning emphasise the potential of high dosage of physical rehabilitation in children and adolescents with acquired brain injury (ABI) during the subacute phase. Clinical research is needed to investigate adequate dosage of physical rehabilitation and its effects on outcome with reliable and valid outcome measures. The aim of this feasibility study is to investigate the safety and feasibility of a high-intensive physical rehabilitation program to improve functioning and participation in children and adolescents with ABI, and to evaluate the feasibility of a coreset of clinical outcome measures for objective assessment of recovery on relevant ICF-domains during the subacute rehabilitation phase.

Methods: A feasibility study was launched on January 1, 2024 using a prospective case-series design. All children and adolescents between 6-18 years of age with ABI, admitted to the inpatient department at De Hoogstraat Rehabilitation, Utrecht The Netherlands, were included. The physical rehabilitation program included a system approach with intensive involvement of parents to reach 3-5 hours physical rehabilitation per day. Physical rehabilitation encompassed planned therapy sessions (physiotherapy, occupational therapy, sports therapy) and supervised and unsupervised physical activities. Standardized measures were used to map physical activity (accelerometery) and fatigue (real-time fatigue scores[RTFS]) along with a coreset of clinical outcome measures for recovery of motor and cognitive functioning (Post-Acute Level of Consciousness Scale (PALOCs), Canadian Occupational Performance Measure (COPM), Gross Motor Function Measure-66 (GMFM-66), 6-Minutes Walking Test (6MWT), Action Reach Arm Test (ARAT) and Cognitive and Linguistic Scale (CALS)) during each individual rehabilitation trajectory. We used process indicators to evaluate the safety and feasibility of this novel approach.

Preliminary Results: To date, 10 participants (mean age 12.3 years, range 6-18 years)) have completed our program with an average of 3.2 hours/day (range 0.5-7.5) of physical rehabilitation. Fifty percent of the participants met the target of 3h/day, with limited consciousness and family availability identified as limiting factors. No adverse events were reported. The coreset of clinical outcome measures was fully administered, however the GMFM and ARAT were found to have limited clinical relevance. All participants demonstrated improvement, with discharge scores exceeding admission scores across all measures, and no adverse effects were observed.

Conclusion: Preliminary results indicate that high-intensive physical rehabilitation during the subacute phase is safe for children and adolescents with ABI. The level of consciousness and family availability may limited the ability to increase the intensity in the early phase of recovery. Therefore the use of standardized outcome measurements is valuable for gaining insights into these factors and supporting clinical decision-making, as well as for assessing recovery of motor and cognitive functioning during subacute rehabilitation for children and adolescents with ABI.

Background: Physical activity positively impacts physical, cognitive and social-emotional functioning in daily life, while also influencing the development of brain structure and function. Therefore, physical activity is considered as an active ingredient of interventions focusing on recovery in children and adolescents with acquired brain injury (ABI), with dosage of practice being recognized as an important factor in determining the efficacy of physical rehabilitation. To date, intensive physical rehabilitation is not yet part of routine daily practice. The aim of our REHABILITY-research program is to synthesize existing knowledge and to generate new knowledge to develop an evidence-based intensive physical rehabilitation program focusing on optimal recovery, functioning and participation in children and adolescents with ABI in the subacute phase.

Methods: In this research project we have adopted a step-by-step approach characterized by close collaboration among researchers, professionals, children and adolescents with ABI, along with their parents. Each stage of the project leverages existing knowledge and experience to inform subsequent steps. The first phase involved the establishment of a foundation for future intervention studies, encompassing: I) a literature review, II) an international expert consensus study, and III) a qualitative study in children and adolescents with ABI and their parents. The findings from these studies were used to design a novel physical rehabilitation program (REHABILITY) in collaboration with relevant stakeholders (phase two). Finally, in the third phase a pilot study will be conducted to investigate the safety and feasibility of this intensive physical rehabilitation program in a single rehabilitation clinic for children and adolescents with ABI.

Results: The first phase revealed that the current body of evidence about physical rehabilitation in children and adolescents with ABI during the subacute phase is limited. International experts, children and their families expressed the need for a more intensive approach, sufficiently tailored to the individual needs of the patient and the family. Subsequently, a consensus-based framework was developed to design an intensive physical rehabilitation program. Principles of neuroplasticity with increased dosage of practice (frequency, intensity, time and type) in meaningful activities, and involvement of parents and siblings are essential components of this novel program. The program is currently being studied for its feasibility (January-December 2024).

Conclusion: Physical interventions during subacute rehabilitation have the potential to improve functional recovery in children and adolescents with ABI, with dosage of interventions as an important factor influencing its effectiveness. Through our program of research we now have an evidence and expert informed intensive physical rehabilitation program designed to challenge children and adolescents to achieve optimal recovery in functioning and participation after their brain injury.

Displays of violence can be a common occurrence following an Acquired Brain Injury (ABI) and can lead to psychological, social, and physical harm for those who experience it. Survivors of ABI who engage in violence can face legal repercussions, social isolation, and may become involved in a cycle of violence. Prevention and reduction of violence requires an understanding of contributing factors, but research findings remain mixed for persons with ABI. Health and wellbeing service providers have a unique perspective as their roles require awareness and understanding of outcomes for individuals with ABI, including violence. Additionally, service providers often face violence directed at themselves from clients and have first-hand experience with contributing factors. Such perspectives can provide insight into how to prevent this behaviour and mitigate harm. The aim of the current study was to explore the relationship between ABI and violence from the perspective of service providers in Victoria, Australia. Individual semi-structured interviews were conducted over the online platform Zoom, with eight (25% female, 75% male) participants from social (4), physical (2), and mental health (2) services. Interviews, on average, were 40 minutes long. Coding and thematic analysis followed an iterative approach. Findings demonstrated that belief in the association between ABI and violence varied, but most participants endorsed a moderate to strong association. Contradictions emerged from participants who believed there was weak association between ABI and violence, who noted that ABI could lead to violence if comorbidities, such as substance use, were present, indicating they did not consider the exacerbating influence of ABI on other predictors of violence. Participants identified additional key factors that may increase the likelihood of violence after an ABI, including changes in cognitive function, impaired social communication, and mental illness. Increased violence was suggested to be influenced by lack of social support, homelessness, and barriers accessing formal support due to financial constraints and complex service systems. It was noted that individuals with ABI experience more difficulty participating in interventions, and experience worse outcomes, than service users without ABI. Overall, participants identified a lack of staff-training to make changes to service delivery that accounted for the unique needs of persons with ABI. This could contribute to poor service outcomes and unmanaged comorbidities that may increase the likelihood of violence. To prevent or reduce violent behaviour, exacerbating factors, such as mental illness and substance use must be addressed. Notably, there is a broad range of potential factors, such as cognitive and social changes, that are beyond the scope of what an individual service can feasibly address. Improved brokerage between different services may resolve this issue by concurrently addressing various areas of concern. Further training and service adjustments are also needed to ensure survivors of ABI receive suitable care.

Introduction: Brain injury is an unexpected event that can drastically alter a person’s life, leading to loss of employment, housing, transportation, independence and social support. In the United States (U.S.), insurance status determines a person’s ability to access healthcare services, ranging from emergency care to preventative services. Following a brain injury in the acute care setting, uninsured persons are more likely to be discharged home and less likely to receive follow up care or rehabilitation, leaving unmet healthcare needs. Individuals who do not have insurance or benefits, such as social security, are not recognized. The aim of this session is to describe the population of uninsured patients with brain injuries served by free rehabilitation clinics in the U.S.

Methods: Colorado, Georgia, and Texas have formed free clinics whose mission is to provide outpatient rehabilitation care, each called the Rehabilitation Services Volunteer Partnership (RSVP) Clinic, whose mission is to provide outpatient rehabilitation care for patients with brain injuries, among other rehabilitation diagnoses. We will report the demographics of individuals attending the free clinic and describe the population of individuals who have experienced catastrophic injury, yet do not have insurance or access to resources.

Results: The states of Colorado, Georgia, and Texas have developed a clinic model to provide needed care to individuals who experience brain injuries and do not have insurance. We will report the demographics of individuals attending the free clinic and describe the population of individuals who have experienced catastrophic injury, yet do not have insurance or access to resources. We will provide insights on how these patients without access to care are living and their goals and needs when they attend clinic. We will describe patients attending these clinics and how they have been impacted by state policies related to Medicaid expansion and injury waivers.

Conclusions: The RSVP Clinic offers opportunity to observe the “invisible” population of individuals who experience brain injuries but are unable to access necessary follow-up care and rehabilitation services. A free volunteer-run outpatient rehabilitation clinic is feasible and can contribute to improved outcomes for uninsured individuals with brain injury. Further research to understand the impact on patient outcomes is needed.

Traumatic Brain Injury (TBI) can occur just once or multiple times during childhood. As a result of TBI in childhood, changes in health, cognition, family environment, and behavior can affect a child’s learning, self-regulation, and social participation. Although children typically recover well from the injury, effects can evolve beyond the injury and be persistent over time, even for milder forms of TBI. This raises the possibility that for some children TBI may require long-term medical follow-up, similar to how chronic health conditions are managed.

TBI affects children differently than adults because it can impact brain development during key periods that may alter developmental trajectories over time. Recent research describes longer term effects in children, including changes in cognition, behavior, and mental health. It has also been documented that there are significant healthcare and school service needs years after the initial injury for all TBI severities. Unmet needs have been documented that include the areas of school support, mental health, communication, pain management, and global healthcare service access. The effects of TBI during childhood can also continue into adulthood as reported by studies examining adults with a history of childhood TBI.

A TBI during childhood can impact development, learning, and social participation. It is important to understand the long-term issues, develop management and treatment approaches, and ensure the child receives monitoring and support over time to ensure good health and wellness outcomes in adulthood. This presentation will describe what is known about the potential longer-term effects of childhood TBI to support the notion that TBI could be characterized as a chronic health condition for children.

Objective: The purpose of this presentation is to describe lessons learned from a model program that was developed to serve adolescents who experienced ABI in childhood during their transition to adulthood by providing insights to achieve good health and assessment of needs in both healthcare and educational/career areas.

Methods: Participatory Action Research methods were utilized for program development by collaborating with focus groups of teen participants and stakeholders. Activities were devised based on best practices for cognitive rehabilitation, direct instruction, and practice of cognitive and metacognitive strategies, technology use, peer coaches and incorporation of multiple stakeholders, including family members.

Results: We learned the importance of technology utilization, completing surveys of vocational interests, peer coaches, and post program follow-up to better understand both healthcare and career needs of adolescents who experienced TBI and are transitioning to adulthood.

Conclusions: Adolescents who experience a childhood ABI benefit from education about the injury effects, technology use for self-management, peer coaches and connection to both healthcare and career opportunities following high school graduation.

This presentation will describe child and adult actions that preceded fall-related traumatic brain injuries (TBI) in young children, chronicle what happens to infants when they fall and sustain a TBI, and report types of assessments to consider for children in the youngest age group.
Previous research has demonstrated that children aged 0–4 years have the most emergency department (ED) visits for TBI among all pediatric age groups, with falls being the leading cause of this injury. Infants younger than 2 years of age are more likely than other age groups to sustain a fractured skull injury after a fall. Child actions (e.g., running) account for the greatest proportion of injuries overall, but actions by others (e.g., carrying) are commonly the cause of skull fractures in children younger than 1 year of age. Examining the circumstances of these head injuries, especially in infants and young children who are unable to provide a report of what happened, is important.
Fall-related TBI in the 0–4-year age group coincides with reaching developmental stages, such as independent mobility and exploratory behavior, at a time when children may not have developed awareness and avoidance of hazards. In particular, children ages 1-2 years are beginning to have independent mobility, which can account for a higher rate of falls in this age group. Environmental modifications, such as modifications of physical space to control access to hazards, like gates, along with improved parental supervision in the home, can contribute to prevention of unintentional falls. Prevention efforts focused on both developmental and parental factors can be considered.
Fall-related traumatic brain injury in young children places them at risk for effects from TBI across development, including behavioral, learning, and social participation. These injuries are a health and developmental concern for young children, highlighting the importance of a comprehensive assessment at the time of the injury to better understand adult actions. Further consideration of child development, parental supervision, and the child’s environment are all important when understanding young children’s falls and designing prevention efforts.

Background: Traumatic injuries, defined as physical injuries with sudden onset, are a leading cause of physical, cognitive, emotional, and behavioral impairments, causing long-term disability. A recent study found that approximately 50% of patients with multiple trauma, traumatic brain injury, and spinal cord injury, had unmet needs for rehabilitation and health services in the first year post-injury. To address these needs, a self-management program, SEMPO, especially tailored to the sub-acute phase (3-4 months postinjury) after trauma has been developed. In preparation for a full-scale randomized controlled trial (RCT), a feasibility study was conducted.

Objective: This non-randomized feasibility study focused on the intervention arm of a planned RCT. The primary study aims were to evaluate recruitment procedures, drop-out-, and attendance rates. Secondary aims included assessing the program’s acceptability, perceived usefulness, and fidelity of delivery.

Methods: SEMPO is a manualized group-based program consisting of eight sessions, each lasting 2-2.5 hours, delivered by a multidisciplinary rehabilitation team. The sessions cover psychoeducation, action planning, training in problem solving, and facilitating peer-sharing experience. The program aims to improve self-efficacy in managing injury-related consequences. To be included in the trial, patients needed to be 18-72 years of age, reside in the southeast region of Norway, and admitted to the Trauma Centre at Oslo University Hospital within 72-hours after moderate to severe trauma, assessed by New Injury Severity Scores > 9. Patients could choose to receive the program either face-to-face or delivered by telehealth. A follow-up at the end of the intervention and after three months was included. Feasibility was evaluated according to pre-defined success criteria (see details in Clinical Trials register: NCT06093074).

Results: Of 24 eligible patients, 11 consented to participate; nine males and two females, with a median age of 46. The consent rate of 46% was lower than expected. The drop-out rate was 9% and attendance rate at sessions was 89%, both deemed highly feasible. Manual adherence in intervention delivery was 97%, also considered highly feasible. Participants rated the program as feasible, and all participants would recommend the program to others, citing peer support and increased understanding of injury consequences as key benefits. The telehealth version delivered to two participants revealed technical difficulties, including equipment restarts and disrupted video streaming, resulting in lower feasibility for the telehealth delivery.

Conclusions: This study demonstrated that SEMPO is feasible for patients in the sub-acute phase after moderate to severe injury, with high retention, attendance, acceptability, and satisfaction rates. However, the low consent rate of 46% indicated a need to improve recruitment procedures before the full-scale RCT. Additionally, the telehealth delivery faced technical challenges, indicating a need for improved technical solutions in the RCT.

Acquired brain injury (ABI) is a life-changing experience for the individuals and their close relatives. Psychosocial support is critical in helping individuals adapt to and cope with the new conditions following a brain injury. However, knowledge about the different components of psychosocial support and their impact on people with acquired brain injury is limited. The aim of this interview study is to develop knowledge about important aspects of psychosocial support in the Swedish health care system by exploring the experiences and perceptions of people with ABI and their close relatives. Participants were aged 18 years and older, and had met with a hospital social worker at least twice. Semi structured interviews were conducted with twenty-three individuals with acquired brain injury and ten interviews with close relatives. The interviews were analyzed using qualitative content analysis. Preliminary findings indicate the importance of person-centered psychosocial support at different stages of brain injury rehabilitation. Participants share a wide range of experiences of accessing and shaping of the psychosocial support. Participants in this study experience a need for hospital social workers who know the common characteristics of having an ABI, but who are also interested in the person on a personal level. The participants is in need of psychosocial support with different designs, especially crisis support, supportive counselling, counselling for the close relatives, information and some practical help. Preliminary findings also indicate a need of a distinct way to access psychosocial support when needed. Keywords: Acquired brain injury, psychosocial support, hospital social worker, user perspective.

Case Description: A 29 year-old female with no significant medical history was rear-ended by a truck as an unrestrained driver. She sustained bilateral intracerebral hemorrhages with leftward midline shift and uncal herniation and underwent a right hemicraniectomy. She was discharged to a long-term care facility (LTAC) for 11 weeks followed by transfer to an acute inpatient rehabilitation facility (IRF). Course in IRF was significant for left-sided pain and spasticity. Gabapentin, tizanidine, and baclofen were continued from LTAC and chemoneurolysis and chemodenervation performed in the left upper and lower extremities. Pain and spasticity improved over time and five months after the initial injury, the patient was medically stable and the decision was made to down-titrate gabapentin with the goal of minimizing polypharmacy and daytime sedation. Seven days after decreasing gabapentin from 800mg to 600mg three times daily (TID), the patient had a new episode of unresponsiveness with left gaze deviation that resolved with diazepam. After unremarkable work-up including bloodwork and brain imaging, this was determined to be an unprovoked seizure. There were no prior seizures documented or observed in this patient. As gabapentin was the only anti-epileptic drug (AED) in use and the only recent relevant medication modification, its dose was increased back to 800mg TID. No seizures were observed afterwards. Electroencephalogram was performed upon resumption of gabapentin 800mg TID and no epileptiform discharges were identified.

Discussion: One labeled indication of gabapentin is adjunctive therapy for partial seizure treatment. Although technically an AED that reduces excitatory synaptogenesis, gabapentin lacks literature assessing its impact on management of post-traumatic seizures (PTS) in the modern clinical setting. Animal models previously demonstrated decreased rates of PTS with gabapentin use and a study in 2024 reported use of gabapentin was more frequently observed in patients without PTS compared to patients who had PTS. In this patient with traumatic brain injury (TBI), gabapentin was not started for seizures but appeared to incidentally help prevent PTS; no other AEDs were used. Even without a history of prior PTS, decreasing gabapentin after prolonged use in patients post-TBI may have the potential to lower seizure threshold. The IRF setting notably offers a controlled environment that is conducive to monitoring for and managing any seizure activity that may occur during the process of gabapentin down-titration.

Conclusions: Patients with TBI are often started and maintained on gabapentin for various reasons post-injury. When attempting to wean off gabapentin in the subacute to chronic recovery period, it is advisable to do so gradually and monitor for potential concurrent development or worsening of seizures. Gabapentin use may help prevent PTS and its efficacy as adjunctive treatment or potential monotherapy should be clarified. Further studies are needed to assess the impact of gabapentin on PTS.

Effective communication with stroke patients requires balancing optimism regarding recovery with transparency about potential long-term outcomes. In a subtype of stroke, angiographically negative subarachnoid hemorrhage (anSAH), patients often receive an overly optimistic prognosis due to favorable immediate (neurological, physical) outcomes. This study examines the prevalence of cognitive impairments, emotional distress, and vocational changes post-anSAH.

Methods: 54 patients (mean age: 53.1 years, SD: 9.1; 26 females) were assessed 4.8 months post-ictus. Neuropsychological tests assessed five cognitive domains: information processing speed, memory, complex attention, executive functioning, and social cognition. Questionnaires assessed executive problems, anxiety, depression, and vocational changes.

Results: Cognitive impairments were identified in 51% of patients, with memory and executive functioning most affected. Executive problems were reported by 22.2% of patients, anxiety by 24.5%, and depression by 20.8%. Vocational functioning was disrupted in 70% of patients.

Discussion: These findings challenge the view of anSAH as benign, revealing significant cognitive and emotional issues and vocational difficulties during the subacute stage. Miscommunication about prognosis may lead to unrealistic expectations, frustration, and psychological distress.

Conclusions: We advocate for clearer communication strategies, comprehensive education, and early neuropsychological assessments to support patient reintegration and improve quality of life.

In the United States, healthcare coverage and services provided through the public health systems vary greatly from state to state. Advocates must navigate ways to influence legislators and other public policy influencers in their own state. Through strategically developed communities in Michigan, the advocates for neuro rehabilitation have been able to both move forward public policies to expand services, while also providing a unified response to negative proposals and legislative changes undermining access to care. Strategically aligned communities with this level of influence take years to develop. Regardless, building these networks should be part of any advocacy planning work. In Michigan, providers of post-acute neuro rehabilitation formed a business council in 1987 in response to early signs that the private insurance industry might try to reduce benefits for people injured in automobile crashes. In 1992 and again in 1994, this council was able to help defeat two ballot proposals that would have gravely undermined care. This group, now called the Michigan Brain Injury Provider Council (MBIPC), has matured to become a leading voice in public policy related to post-acute care in Michigan. In the early 2000’s, MBIPC realized they would not be able to hold off the influence of the insurance industry alone and began considering ways to strengthen their influence. In 2004, MBIPC initiated the formation of a multi-agency lobbyist group, creating the Coalition Protecting Auto No-Fault (CPAN). The Coalition included key associations that already had long standing relationships with policy makers, including the Michigan Hospital Association, the Michigan Association for Justice, the Disability Rights Coalition and others. This new coalition was successful in protecting neuro rehabilitation in Michigan until 2019 when major legislative changes gutted funding for post-acute care. Once these major changes occurred, the families of those living with brain injuries formed their own grassroots coalition through a Facebook group called We Can’t Wait. This group quickly grew to over 8,000 advocates. They formed a very strong and highly visible consumer group and became a key voice to have alongside the providers whenever working on policies impacting care. With the alignment of these three advocacy communities, MBIPC, CPAN, and We Can’t Wait, Michigan likely has some of the most well organized and coordinated multi-level state advocacy for post-acute neuro rehabilitation anywhere in the United States. The communities have been able to strategically work together to align their voices and become key constituents on policy initiatives and proposals impacting access to and funding for the neuro rehabilitation continuum of care.

Introduction: According to the most recent Consensus Statement on Concussion in Sport (Amsterdam 2022), up to 30% of children and adults with sport-related concussion experience persisting post-concussive symptoms which is defined as symptoms lasting more than one month. However, studies included in the systematic reviews of the Amsterdam 2022 consensus didn’t include concussion/mild Traumatic Brain Injury (mTBI) in non-athletic population. The aim of this systematic review was to document the mTBI symptom resolution rate at different time points in a non-athletic adult population and to identify the prognostic factors influencing recovery in this population.

Methods: A literature search was conducted in the Embase, Ovid Medline and CINAHL databases. Inclusion criteria were: non-athletic population between 18 and 65 years of age with acute mTBI, prospective cohort studies with a minimum follow-up of one month, and post-concussion symptoms as a measure of recovery. The number of recovered patients at each follow-up was extracted from the studies as well as the reported prognostic factors. The risk of bias of each included study was assessed using the QUIPS assessment tool for prognostic factor studies.

Results: Of the 16 included studies, the risk of bias was high for two studies, moderate for ten studies, and low for four studies. At one, three, six, and 12 months, the proportion of full symptom recovered patients were 55.6% (253/455), 54.9% (365/665), 52.3% (405/774), and 61.8% (102/165), respectively. The intensity and number of initial symptoms and psychiatric history were the most reported prognostic factors. High age, female gender and education levels appear to have limited predictive potential.

Conclusion: Up to 45% of adults still experience symptoms at one month following a concussion/mTBI in a non-athlete population which is significantly higher than the sport-related concussion population. The intensity and number of initial symptoms and psychiatric history remain the most reported prognostic factors.

Background: Youth concussion recovery is variably described as ‘unique’, ‘individual’, and ‘unpredictable’, yet the concept itself is rarely defined, and little scholarship has been directed toward understanding what recovery ‘is’ (e.g., what recovery looks like, what constitutes a ‘good’ or ‘full’ recovery, how youth understand their own recovery). This omission represents a major gap in knowledge of youth concussion with significant implications for the development and delivery of clinical supports and services.

Method: Combining a structured critical conceptual review with elements of critical interpretive synthesis methodology, we examined fifteen texts (e.g., empirical studies, clinical guidelines) published between 2018 and 2023 that implicitly and/or explicitly conceptualized youth concussion ‘recovery’. Our approach was grounded within a Foucauldian theoretical orientation that enabled us to consider the literature not as the self-evident ‘truth’ of concussion ‘recovery’ but as an object of inquiry in of itself. Accordingly, we approached the literature with an eye toward identifying and examining the patterned ways of speaking, thinking, and acting (i.e., discourses) that were produced and reproduced across texts to the extent that they appeared as ‘just the way things are’. Our review was framed by the following questions: how is youth concussion ‘recovery’ conceptualized in the health and rehabilitation literature?, what taken-for-granted assumptions underlie what ‘recovery’ is represented to be?, what are the potential effects of such assumptions on youth and their families, and on how youth concussion is intervened upon in health and rehabilitation? Our team-based approach to analysis was informed by our Foucauldian theoretical orientation.

Results: Through our critical analysis, we identified what we term ‘a dominant narrative of youth concussion recovery’. Central to this narrative is the representation of ‘recovery’ as progressing along a predetermined timeline beginning at the time of injury and ending with a return to ‘normal’. Within this narrative, youth and their families are expected always to be working toward the endpoint of normality. Our analysis suggests that this dominant narrative was rarely questioned across reviewed texts. Drawing on illustrative examples from the reviewed texts, we demonstrate the ways in which ‘recovery’ - as currently conceptualized - is a reductive ableist concept that perpetuates harmful assumptions about the sorts of bodies and childhoods that are valued in contemporary society.

Implications: This work suggests that conceptions of recovery ought to engage more directly with the experiences and perspectives of youth. Future research in this area has the potential to shift clinical practices in ways that are attuned to life after concussion (e.g., away from ‘recovering normal’ and toward adjusting or adapting to life with symptoms).

Objectives: To determine if ABA interventions can be a useful approach to maladaptive behavior in acute rehabilitation setting following ABI.

Background: Behavioral disturbance after acquired brain injury (ABI) can be considered within the framework of a temporary dysfunction of fronto-temporal systems. Dysfunction of these offline neural networks leads to impaired executive function and memory encoding. These, coupled with poor insight and deficit awareness (anosognosia), lead to a loss of top down modulation of behavioral output resulting in maladaptive behavior. Consequences of such network dysfunction can range from a mildly irritable patient to one who is combative with severe impulse dyscontrol. The challenge confronting the practitioner is how to get the affected patient through this temporary period of confusion, amnesia and heighted behavioral dyscontrol – also known as post traumatic amnesia (PTA) - without injury to the staff, family or patient. The physician that is directing care in acute rehabilitation centers is often asked to manage these patients’ behaviors during this period without the proper tools to manage their fronto-temporal injury.

Methods: To address an inadequacy of common approaches to behavioral disturbance arising from fronto-temporal injury, we have explored the use of ABA utilizing a Board-Certified Behavioral Analyst (BCBA) on an acute inpatient rehabilitation unit. BCBA directed ABA science is a validated and widely accepted approach that has been used for decades in the field of autism spectrum disorder and other developmentally challenged individuals, as well as in transitional programs specializing in persistent behavioral disorders after ABI. We believe that we are the first to bring such a program to an acute inpatient ABI rehabilitation unit.

Results: Since implementation of BCBA clinicians on an inpatient ABI unit there has been a marked reduction in staff injury and a reduction in costs related to managing aggressive patients with frontotemporal injury. Additionally, there was an overall improvement in staff and family confidence in dealing with the temporary period of confusion that often follows ABI.

Conclusions: This approach was found to be extremely successful in both patient and family outcomes as well as staff safety and satisfaction. Additionally, in the first year of implementation there was an estimated savings of $110,000. This presentation will discuss the integration of a BCBA into the acute inpatient rehabilitation unit and how these tools and techniques can generalize to other settings.

The GABAergic drugs, lorazepam and zolpidem have shown to produce paradoxical increased consciousness in patients with Disorders of Consciousness (DoC), however their effects on motor recovery and spasticity have not been well described.1,2 We highlight a case of emergence from a minimally conscious state (MCS) after initiation of lorazepam in a patient with traumatic brain injury (TBI) with accompanying improvements in movement initiation and spastic tone. An 18-year-old male was admitted to a DoC rehabilitation program with a history of severe TBI suffered four months prior with resultant spastic quadriplegia. Initial imaging had revealed bilateral hemorrhagic contusions, a left subdural hemorrhage, and a right parietal epidural hemorrhage requiring an emergent right temporoparietal craniotomy and a left fronto-temporoparietal decompressive hemicraniectomy with subsequent left cranioplasty. The patient’s presentation was consistent with a MCS (CRS-R score 13) and management with amantadine and modafinil failed to improve arousal. A trial of lorazepam (2 mg) resulted in improved alertness and emergence from MCS (repeat CRS-R score 22). Scheduled lorazepam therapy (2 mg daily) resulted in an improved ability to move his thumb to answer yes/no questions and reduced spastic tone in bilateral upper extremities, allowing for discontinuation of baclofen therapy. It is theorized lorazepam and zolpidem hyperpolarize GABAergic neurons in the globus pallidus interna (GPi), relieving active inhibition of the central thalamus, and restoring thalamocortical activity.3 In this case, the marked improvement in motor planning and spastic tone with lorazepam was most similar to reports of emergence from MCS with catatonic features.4 The patient’s injury pattern likely coincided with a density of striatal GABAergic neurons or GPi GABA-A receptors, resulting in an inhibitory-excitatory imbalance between striatal, thalamic, and cortical structures. Lorazepam was able to resolve the effects of deafferentation and terminate active inhibition by the GPi leading to marked improvement in arousal and spasticity.

Background: As young children age, a greater number of traumatic brain injuries are sustained outside of the home, frequently occurring in daycare and school settings. Prevention strategies to reduce mild traumatic brain injury (mTBI) primarily target mechanisms of injury, with notable differences in the way injuries occur according to age. Limited epidemiological data exists on mechanisms of injury among children in these settings.

Objectives: To describe the mechanisms of mTBI and details surrounding injury context among children 0-5 years presenting to Canadian Emergency Departments who experienced mTBI in daycare and preschool settings.

Methods: The Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects information from patients with injuries who present to 20 emergency departments across Canada. All children 0-5 years old in CHIRPP who experienced unintentional concussion or mild head injury in daycare or preschool locations between 2012-2022 were included in this study. Descriptive statistics were calculated to determine the mechanisms of injury and context details.

Results: Approximately 3063 children aged 0-5 years (Median age at injury= 2 years) old experienced mild traumatic brain injury in daycares and preschools across this ten year span, with the majority of injuries occurring indoors (62%), whilst children were playing (43%). The primary mechanisms of injury were falls (78.5%), being struck/hit by an object (21%), and transport-related (0.6%). Injury surfaces and objects primarily involved floors, concrete surfaces, and tables and most frequently included other children.

Conclusions: In daycares and preschools, falls are clearly the main mechanism of mTBI, with most injuries occurring indoor, during play. These results can inform prevention and knowledge translation programs within these settings.

Purpose: People living with neurological disorders including brain injury have high rates of persistent pain. This mixed methods pilot study was designed to explore the impact on psychological and functional outcomes of a nine-week Pain Management Group (PMG) for clients with both a neurological diagnosis and persistent pain.

Methods: A pre- and post-test design was used. Measures of subjective pain intensity (Numeric Rating Scale of Pain), quality of life (Rand SF-36), pain catastrophizing (Pain Catastrophizing Scale), pain acceptance (Chronic Pain Acceptance Questionnaire) and occupational goal performance (Canadian Occupational Performance Measure) were completed at three time points: Time 1 (pre-treatment), Time 2 (end of treatment), and Time 3 (follow up 3 months after treatment). A qualitative exit interview was done at Time 2. 53 participants with neurological disorders including brain injury, spinal cord injury and multiple sclerosis were recruited and 44 provided at least partial data at all 3 time points.

Analysis: To assess the primary objective of change in scores at Times 1 and 2, paired t-tests were performed for continuous variables and Signed rank texts for discrete variables. Exploratory repeated measures analyses were performed to assess if there were any differences between groups defined by sex, diagnosis type, age, and number of treatment sessions attended at all 3 time points. Measures were also compared to reported pain scale at each time point using Spearman ranked correlations. Constant comparative analysis was conducted on qualitative data and themes were developed.

Findings: Statistically significant positive changes were found between T1 and T2 on measures of pain catastrophizing (mean change: 6.7 (9.3); p=0.0004), acceptance of pain (mean change: -9.0 (12.6); p=0.0003), health-related quality of life (mean change: 8.2 (14.1); p<0.0001), goal performance (mean change: -3.4 (2.0); p<0.0001) and goal satisfaction (mean change: -4.5 (2.1); p=0.0022). Gains were maintained to Time 3. The qualitative analysis offered themes around the importance of peer dynamics, strengths and challenges with the group format, and experiences with applying group content to daily

Discussion and Conclusions: Results support that the PMG shows potential as a beneficial persistent pain treatment for improving psychological status, functional abilities, and health-related quality of life in persons with neurological diagnoses.

Background: Alcohol plays a complex role in Irish society and is associated with many aspects of Irish social life and is also routinely consumed at home. The societal cost of alcohol use in Ireland is estimated at 3.7 billion euro per year with annual healthcare costs estimated at up to 1.5 billion euro. However this is thought to be an underestimation due to coding practices in Ireland. Understanding the burden of alcohol on the health is an important element in informing public health policy decisions and appropriate resourcing in healthcare. The incidence of alcohol-related traumatic brain injury and the associated healthcare costs in Ireland is not well understood. AIMS: This study describes the epidemiology of alcohol-associated traumatic brain injury admitted to a major trauma centre (MTC) in a 9 month period. We aim to quantify resources required for this patient cohort during their in-patient stay.

Methods: This is a retrospective study including patients who were admitted to a major trauma centre and reviewed by the inpatient trauma service (IPTS). Patients were categorised as “alcohol-associated” trauma based on self-declaration of consumption of alcohol, reference to intoxication in the initial patient assessment by emergency medicine or on prehospital documents and ethanol levels taken in the Emergency Department. Traumatic brain injury (TBI) includes all patient who had head injuries inclusive of mild concussion to severe brain injury. Length of admission, requirement for ICU, number of operative interventions, and discharge destination were used as surrogates for resources required.

Results: 644 patients were reviewed by the IPTS between 1st Jan to 30th Sept 2024. 164 of these patients had TBIs. 44 of these patients had alcohol-associated TBIs, 34 were male. Of the 44 patients, 48% (n=21) had a injury severity score greater than 15, indicating severe injury. 30% (n=13) required admission into ICU, and 20% (n=9) required neurosurgical intervention. In total 466 bed days were taken by this cohort of patients. 27% (n=12) were transferred to another acute hospital, discharged to a rehab facility, or remain in the MTC. 48% (n=21) were discharged home and 1 died due to their injury. Examining the mechanism of injury; 30% (n=13) fall < 2 metres, 23% (n=10) fall >2 metres, 25% (n=11) assault, 14% (n=6) road trauma, and 9% other.

Conclusion: Patients who were admitted to CUH with head injuries sustained in the context of alcohol present require the input of significant resources and hospital bed days. The most common mechanism of injury was falls. During admission in the MTC, patients require input from multiple medical/surgical specialities and allied healthcare professionals. 27% of these patients required discharge to a lower level acute hospital or rehabilitation facility, indicating ongoing cost to the public healthcare system.

Introduction: Intimate partner violence (IPV) often results in brain injuries (BI) from direct trauma such as blows to the head or non-fatal strangulation. Although the cognitive impairments arising from IPV-BI are crucial to understanding the full impact on survivors' quality of life, there has been limited quantitative analysis on how these impairments correlate with the severity of IPV-BI. Cognitive deficits can impair daily activities, decision-making, and overall well-being but are frequently overlooked in clinical assessments. This study aims to assess cognitive functions among IPV-BI survivors compared to healthy controls to explore the relationship between the severity of IPV-BI and cognitive function.

Methods: Participants were women aged 18-50 who had experienced IPV, recruited through various community support organizations (n = 41). Cognitive domains – including memory, reasoning, concentration, attention, and executive function – were assessed using the Creyos Platform. Performance of the participants was compared to that from the Creyos normative database with approximately 12,000 female participants aged 20-50 years using independent t-tests. Assessments of IPV-BI severity (Brain Injury Severity Assessment - BISA), post-traumatic stress disorder (PTSD) (PCL-5), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and adverse childhood events (ACE) were also collected.

Results: Results from an independent t-test revealed that IPV-BI victims exhibit significantly greater cognitive impairments compared to the non-IPV-BI population. Particularly, differences were observed in visuospatial working memory (p = 0.039), working memory (p = 0.001), verbal short-term memory (p = 0.001), and visuospatial processing (p = 0.022).

Conclusions: Preliminary results indicated significant cognitive impairments in IPV survivors with BI compared to healthy controls. These deficits were largest in assessments of memory and attention and much smaller for reasoning and executive function. The findings highlight the need for targeted interventions and support systems to address the cognitive and psychological needs of IPV-BI survivors. These results have potential implications for public health policies and clinical practices, emphasizing the importance of recognizing and treating cognitive impairments in IPV-BI survivors.

Physical exertion tests have been used to assess concussion-related symptoms and guide return-to-play in athletes. However, they can also be used to threshold subsequent exercise intensity during prescribed exercise interventions by determining individual heart rate (HR) at exercise-induced symptom exasperation following mild traumatic brain injury (mTBI). Despite this, current tests provide limited metrics (i.e., no physical fitness data) with no data being published on their efficacy in determining thresholds for subsequent exercise intervention sessions in community-dwelling individuals with mTBI. (i.e., non-sport-related TBI). Therefore, we aim to provide preliminary data on the feasibility of the Boston Exercise Symptom Threshold Test (BESTT) in community-dwelling individuals with mTBI and to test the efficacy of the test on thresholding subsequent aerobic exercise intervention sessions as part of an ongoing pilot randomized control trial (NCT06494592). 24 community-dwelling adults (29.79±11 yrs.), physician-diagnosed with mTBI within 12 months of initial injury, completed a three-phase test on a cycle ergometer. Phase one involves a seven-minute warm-up with no restrictions, or resistance. Phase two involves a six-minute sub-maximal cardiorespiratory fitness test (Modified Astrand Rhyming Cycle Test) followed by progressive increases in cadence and resistance (Phase three) until stopping criteria is reached (≥ three-unit increase in symptom severity or safety/volitional exhaustion). HR and symptom severity were collected every two minutes. HR at individualized symptom threshold (the point at which a ≥ three-unit exercise-induced symptom severity increase from baseline is observed) is then calculated and used to threshold 30-minute aerobic exercise sessions delivered three-times per week. No adverse events were reported during the test nor any of the subsequent exercise intervention sessions. All 24 participants completed phase one of the BESTT allowing for the estimation of cardiorespiratory fitness. 45.8% of participants ended the BESTT due to reaching symptom threshold, 37.5% were due to exhaustion, and 16.7% were due to reaching their age-predicted max HR. On average, the test lasted 9.56±3.24 minutes. Data from the first two-weeks of aerobic exercise intervention showed that 91.6% of participants exercised within, or above, 65 – 80% of their symptom threshold without experiencing symptom exasperation. Linear mixed effects modeling involving ratings of perceived exertion (RPE), HR, and time revealed a significant effect of HR (β = 0.038, p < 0.001, CI = 0.018 – 0.058) and timepoint (β = 1.023, p =< 0.001, CI = 0.780 – 1.265) on RPE. Meaning, as HR increased, RPE also increased over time. The BESTT is a feasible physical exertion test for community-dwelling individuals and provides accurate information that allows prescribers to threshold aerobic exercise sessions that do not increase mTBI-related symptoms. Thresholding exercise-induced symptoms through a systematic test, like the BESTT, will allow ‘exercise is medicine’ interventions to reach more individuals recovering from mTBI, beyond sport-related concussion populations.

Background: Given the fast-paced and high-stakes learning environment of university settings, students with concussion are at particular risk for negative academic as well as psychosocial consequences. Concussions are more common in non-student athletes than athletes, which means that most students will not be connected to systems of care for identification, diagnosis, treatment, and other management approaches. Instead, students must often self-advocate and navigate these systems independently during their recovery. In this study, students with recent concussions and persistent symptomatology received mentoring from students who had previously sustained concussions and successfully returned to school as university students. Here, we evaluated the emotional valence of student descriptions of experiences participating in the peer mentoring program.

Methods: Eight mentees with concussion completed the Success in University and College after Concussion with Effective Student Supports (SUCCESS) program followed by a semi-structured exit interview. Students averaged 21.9 years in age and 4.1 months post injury (range 1 to 7 months). Three identified as male, five as female. Five students were White, two Asian, and one Black. Injury mechanism included sports, struck by/against, and motor vehicle crash. Interview questions addressed concussion and recovery experiences, along with reactions and feedback around mentoring. Probes were either neutral, or for both positive and negative exemplars. Interviews were transcribed, then coded using thematic analysis. Themes were subjected to sentiment analysis using NVivo version 14 to identify positive and negative statements, and a chi-square test was applied to compare distributions of frequency counts across categories.

Results: From thematic analysis, six themes emerged, specifically: Academic Performance and Load, Accommodations and Adjustments, Changes in Function and Daily Living, Uncertain Concussion Knowledge, Interest In and Impacts of Peer Mentoring, and Recovery and Rehabilitation. There was a non-significant trend toward Accommodations and Adjustments, Interest In and Impacts of Peer Mentoring, and Recovery and Rehabilitation being more positive than the other themes (X2 (5, N = 196) = 10.68, p = .058). Instead, experiences were mixed across themes, with both positive and negative statements.

Discussion: Experiences following concussion as a university student are expressed both positively and negatively, reflecting both the difficulty of the concussion effects and its academic and broader impacts, as well as the influence of positive supports and accommodations on symptom resolution and re-integration into student life. Even though student mentees in the current study had completed the intervention, re-entered school, and described symptoms as resolving, they appeared to continue to process both positive and negative aspects of their experience. Future work should further examine whether such sentiment measures are sensitive to change over time following concussion, how prompts impact elicitation of sentiment, and if emotional valence of linguistic output may be useful as a measure of response to intervention following concussion.

Background: Fluent reading crystallizes across the early school-age years. Reading is based in language, particularly phonological processing, but also relies on cognitive and visual systems that are susceptible to the effects of mild traumatic brain injury (mTBI). For example, cognition underlies activities such as remembering and linking information, monitoring of comprehension, and deciding when and what strategies might be needed. Oculomotor function allows the eyes to move fluidly across lines of text and down a page. Reading comprehension is critical toward academic success, and increasingly, reading is a key form of communication through social media, texting, and emails. Unfortunately, reading has been understudied in children and is often overlooked in clinical care and rehabilitation for mTBI. To inform future research and clinical care, the purpose of the current case series study was to examine whether children receiving neuropsychological testing following concussion might be at risk for reading problems. Methods: In this retrospective chart review, we extracted data from outpatient neuropsychological reports. In this clinic, a measure of reading comprehension was included in all pediatric assessment batteries. Chart inclusion criteria were: age between 5 and 18, diagnosis of mTBI, complete Woodcock-Johnson Passage Comprehension scores. Because we chose a case series design, no other exclusion criteria were applied. Two trained research assistants extracted data. A third trained research assistant reviewed extraction and resolved any inconsistencies through discussion and document review. Results: Eight charts met inclusion criteria. Children’s ages ranged from 6;11 to 16;2 at the time of assessment. Time post injury similarly ranged widely from one week to 2.8 years. All spoke English as their dominant language, seven were White and non-Hispanic (the other declined to respond), and five were male. Most had a complicating pre-morbid learning condition, of which Attention Deficit/Hyperactivity Disorder was most common. Only two students had Passage Comprehension standard scores above 85: an 11;1 male (SS=99) and a 16;2 female (SS=92). Three children scored at or below one standard deviation (SD) below the mean (85, 81, 79), one 1.5 SD below (74), and two scored more than two SDs below the mean (68, 55). Discussion: Children with a history of mTBI seeking neuropsychological testing may benefit from screening for reading problems. While the current design and sample size did not allow for pooling of data or examination of contributing factors, reading problems may be common in those seeking this type of characterization of strengths and weaknesses, whether from developmental or acquired conditions. Given the impact that reading impairments can have on learning and communication, future work should examine a broader sample of children with mTBI to be able to understand factors that might be contributing to difficulty reading, as well as those conducive to rehabilitative approaches.

Play is a crucial part of a child’s identity and as such has been recognized by the United Nations Convention on the Rights of the Child that all children have the right to engage in play. Play provides many physical, psychological, social, and emotional benefits, and is especially important during the pre-school (ages 3 to 4 years) and school-aged (ages 5 to 12 years) years. A variety of play opportunities including unstructured (or child-led) play and structured (or adult-led) play are recommended for healthy development. After experiencing concussion, physical and cognitive symptoms can impact how children safely reengage in play. Given the risk for all children to experience concussion, there is ample research related to pediatric concussion including its symptoms, and return to school and return to play recommendations. Following concussion, it is recommended that children follow defined and evidence-based protocols to return to play. However, oftentimes the ‘play’ emphasized in these protocols is specific only to sport. To date, there is a lack of exploration and consolidation of post-concussion return to play recommendations that encompass the broad play experienced by children aged 3 to 12 years.

Objectives: The purpose of this scoping review is to determine the extent of and summarize the literature regarding recommendations for returning to play following a concussion for children aged 3-12 years.

Methods: The Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol extension for Scoping Reviews was followed for this review. Studies were included if they: 1) included participants aged 3-12 years who have had a concussion; 2) included formal or informal intervention for returning to play following concussion; 3) were published in a peer-reviewed journal; and 4) were available in English. Six databases were searched.

Results: 20,248 articles were initially and 8,7469 duplicates were removed using Covidence, totalling 11,499 articles to be reviewed. 267 studies were eligible for full-text review and 15 papers met the eligibility critera after full-text review. Based on preliminary data extraction, 53% (n=8) of studies were conducted in Canada, 67% (n=10) were published between 2010 and 2020 and 53% (n=8) were cohort studies. Prior to returning to play, studies recommended activity restrictions (n=4), medical monitoring and management (n=4), gradual return to physical activity (n=4), identification of co-morbidities (n=2), active rehabilitation (n=2) and objective testing (n=1).

Implications: This research provides a consolidation of the play literature which is important in determining what post-concussion evidence-based recommendations are known for this age group. This research also explores the type of play (e.g., unstructured) and context (e.g., school) in which the play is occurring, which is essential for identifying gaps and informing future recommendations for returning to play.

The psychiatric recovery process of Women with traumatic brain injury (WwTBI) is a subject that has insufficient scientific evidence and analysis. Optimizing the management of WwTBI, requires collection and analysis of lived experiences including the psychosocial impact on those affected. We were asked to evaluate a unique literary anthology (LA) written by prestigious women authors with lived experiences of TBI. With our previous experience in analyzing qualitative data amongst athletes through interviews and our documentary (A Dark Room) we felt that applying a similar iterative process to this anthology could serve as a template for understanding future narrative collections. Using a qualitative approach the St. Michael’s Hospital Brain Injury Clinic team approached 152 potential participants, of which 8 consented and 6 completed the protocol. Two participants withdrew from the study. Two focus groups were established which were composed of researchers and patients from the psychiatry clinic. Questionnaires, individual and group interviews were conducted pre and post reading the LA. The recordings and questionnaires were transcribed into written data. The collective data was then coded using the Braun & Clarke 6 step framework for thematic analysis. We then connected with the authors to see if the themes we developed coincided with the authors’ interpretation of the LA. We were able to determine a pattern of consistency between what authors wanted to portray and what readers were intended to understand. We can recommend this template as a repository of themes for future knowledge translation (KT) activities with the hope of providing more impactful care for WwTBI.

Introduction: Medical complications occur frequently in the minimally conscious state (MCS) and influence advance medical decision-making. Within a nationwide network of centralized care for patients with a prolonged disorder of consciousness (PDOC), a nationwide prevalence study on MCS was conducted, which also provided the opportunity to study to collect clinical data. This study aimed to report on medical complications and advance medical decision-making in a nationwide group of MCS patients.

Methods: In this descriptive nationwide cross-sectional study, patients with a possible PDOC were reported by medical directors of hospitals, specialized PDOC rehabilitation, and nursing homes. We aimed for 100% verification of the level of consciousness (LoC) with the Coma Recovery Scale-revised. Characteristics on medical complications and advance medical decision-making characteristics were collected in a questionnaire, completed by the treating physician. In this questionnaire, the following characteristics were asked: etiology of brain injury, level of consciousness, presence indwelling devices such as gastric tubes and tracheostomy, and medical complications from the onset of brain injury. Also, treating physicians were asked to report the current agreed-upon treatment scenario, the scenario they thought was most appropriate, and could report any details about the conversations held about advance medical decision-making.

Results: Seventy patients with a possible PDOC were reported, 49 of whom the level of consciousness was verified with the Coma Recovery Scale-revised. The MCS population consisted of 32 patients: 65.6% traumatic etiology, 68.8% male, one patient was admitted to the hospital (3.3%), 17 to specialized PDOC rehabilitation facilities (53.1%), and 14 to nursing homes (43.8%). Almost all patients had (naso)gastric tubes (n=31), 11 a cerebrospinal fluid shunt, and 6 a tracheostomy. The median number of medical complications per patient was 2-10 (median 5). Hypertonia/spasticity (81.3%) and pneumonia (50.0%) occurred most frequently. Characteristics about advance medical decision-making showed that most patients had curative goals: 3 patients had a fully curative treatment scenarios, 29 a scenario with ≥ 1 treatment restrictions. Of the patients with treatment restriction, the scenarios were described as palliative in two patients, and as symptomatic in two other patients. Conversations about medical treatment were complicated by disputes with next of kin, inability to evaluate medical treatment because of medical instability, next of kin not being ready to discuss medical treatment, or a treatment scenario explicitly based on requests of next of kin.

Conclusions: Medical complications are common in MCS patients and legitimate deployment of specialized care across acute, post-acute and long-term care. Treatment scenarios mostly have a curative character and discussions about medical treatment can be complicated. Further longitudinal research is recommended to improve the understanding of the process of advance medical decision making.

Introduction: Approximately 70-90% of traumatic brain injury experienced are classified as mild (mTBI). MTBIs are characterized by immediate and transient changes in brain function that result from a complex series of metabolic events. In general, patients experience pronounced symptoms and difficulties within the first 72 hours, which diminish over the first two weeks before disappearing completely after 3 months. However, 10 to 25% of patients will continue to report persistent and disabling symptoms during the chronic phase, i.e. more than 3 months after the event. Considering the prevalence of mTBIs, this percentage translates into a considerable number of people who will experience a reduction in well-being. Existing research has indicated that the onset, intensity and duration of mild post-mTBI symptoms are influenced by a combination of factors related to the lesion itself (mainly neurological) and, above all, factors unrelated to the lesion (mainly psychological). It is then likely that the complex interplay between the individual's set of pre-existing characteristics (e.g., personality traits and emotion management) and the impact of the injury play a predominant role in maintaining problems post-mTBI. In turn, this could prevent some patients from returning to their pre-injury level of functioning. However, these factors have not been exhaustively studied in reference to mTBI recovery. Thus, the aim of this study is to document the personality profiles and emotional regulation of patients with and without persistent symptoms after mTBI.

Methods: Until now, 26 patients were recruited from Montreal's Hôpital Sacré-Coeur and separated into two groups: 12 with a favorable outcome (OC+) and 14 with an unfavorable outcome (OC-) based on their symptoms three months after the accident on the Rivermead Questionnaire. Patients completed the Minnesota Multiphasic Personality Inventory-3 (MMPI-3), the Emotional Regulation Questionnaire and the Impact of Event Scale.

Preliminary Results: Two-way T-tests (comparing the OC- and OC+ groups) revealed differences in the MMPI-3 somatization and neuroticism scales, with significantly higher scores for the OC- group. There were also differences in emotional regulation strategies, with significantly higher scores for inadequate strategies in the OC- group. Finally, a significant difference was found on the Impact of Event Scale: the OC- group had higher scores than the OC+ group.

Conclusions: These results indicate that individuals with persistent symptoms after mTBI show distinct psychological and emotional patterns compared to those with a favorable recovery (higher somatization and neuroticism, maladaptive emotional regulation strategies and accident impact). The data from this project will be used to create tailored intervention strategies that are better adapted to the patient's profile and outcome, in order to promote their recovery. Additionally, it will better equip healthcare professionals working with this population.

Introduction: Acquired brain injury (ABI), particularly dysexecutive syndrome, can significantly limit daily activities and hinder employment. GUSTO-WORK, a two-month culinary group intervention (2 x/week, 120h), was designed to develop transferable work skills through food literacy-related activities (i.e. meal planning, budgeting, cooking, cleaning...). GUSTO-WORK is provided by an occupational therapist in a professional kitchen. In the second month, a chef provided additional instruction to enhance cooking techniques.

Objectives: The study aimed to (1) explore the effects of GUSTO-WORK on cognitive function, real-life cognitive processes, functional displacement, and occupational outcomes, (2) determine whether occupational gains are maintained for three months post-intervention, and (3) document occupational outcomes.

Methods: A single-case experimental design with repeated pre- and post-intervention measures was used with 6 adults with ABI and executive dysfunction (mean age 55 ± 14.85 years, 3 females). Ecological cognitive processes were assessed with the Cooking Task (CT), and work-related personal goals with the Canadian Occupational Performance Measure (COPM). Attention, inhibition, working memory, memory, and displacement under cognitive load were measured using the Test of Everyday Attention (TEA), the Stroop test, the N-back, the Rivermead Behavioural Memory Test (RBMT), and the Timed Up and Go (TUG). For group analysis, changes in average pre- and post-intervention performance were analysed using paired t-tests and Wilcoxon tests, where the mean of all pre-intervention measures was compared to the mean of all post-intervention measures. For individual progress, all measurement points across multiple baselines were analysed using non-overlap of pairs (NAP) and visual analysis of plotted raw data. Statistical significance was set at p <0.05.

Results: Group analysis revealed significant improvements across multiple domains. In the cognitive domain, participants showed better recall in both visual (p = 0.027) and verbal memory (p = 0.026; RBMT), along with improved visual target search (p = 0.044 and p = 0.031; TEA). For functional displacement, significant improvements were observed in basic displacement (p = 0.018; TUG 1) and displacement under cognitive load (p = 0.010; Dual TUG 1). For cooking performance, results revealed fewer total errors (p < 0.001), fewer control errors (p = 0.007), and reduced context neglect (p = 0.011; CT). No significant change was observed in Stroop performance. The NAP analysis nuanced these group findings by highlighting individual variability in performance evolution over time. Occupational outcomes were positive for 5 of 6 participants, with significant improvements in goal performance and satisfaction (COPM). At the end of the program, one participant continued rehabilitation, two retired to voluntary work, and three returned to work.

Conclusions: GUSTO-WORK showed potential for cognitive and functional improvements in real-life contexts for adults with ABI and executive dysfunction. The occupational gains observed suggest that the skills developed were transferable, supporting community participation and workplace reintegration

Introduction: Cognitive and communication disorders (CCDs) after acquired brain injury (ABI) typically have a considerable negative impact on successful social and vocational rehabilitation (Douglas et al., 2016, Meulenbroek & Turkstra, 2016). CCDs often affect daily situations that place a high demand on cognitive functions (e.g., communication situations with background noise). Due to their structured, often paper-pencil based format, existing standardised assessment tools cannot reflect these demands of daily life. We therefore aim to develop an innovative, participation-oriented assessment tool for individuals with CCD after ABI. This tool, Commbi (Cologne-Bielefeld Communication Assessment Combined), combines two diagnostic approaches: (a) a Patient-Reported Outcome Measure (PROM) for self-evaluation of everyday and vocational communication abilities (Commbi-PROM), and (b) a functional assessment of everyday and vocational communication abilities in real-life oriented communication contexts in virtual reality (Commbi-FUNC(tional)).To ensure the clinical relevance and acceptance of 'Commbi' for people with CCD, we use a co-design approach: Within a module for Patient and Public Involvement and Engagement (PPIE) individuals with CCD after ABI and their relatives are to be involved in the conception process of Commbi. The talk will outline the results of the first Co-design process, which aimed to identify which communication situation and stressors in daily and vocational life are identified as challenging for individuals with CCD after ABI. Further, consequences for the development of the Commbi will be described.

Methods: Based on a comprehensive literature search, challenging everyday communication situations and scenarios as well as potential items for Commbi-PROM were identified. Subsequently, we conducted semi-structured interviews with individuals with CCD after ABI (n = 5), who aimed at requesting their experiences with challenging communication situations and stressors in everyday life and vocational life. Our interview-manual involved open questions on participants’ experiences as well as ratings (e.g., on the importance and/or impact of certain stressors) addressing three different everyday-contexts: (i) communication in vocational context, (ii) public communication with a non-familiar person, and (iii) personal conversation with a familiar person.

Results: Data acquisition is still in progress. The talk will present the results of the first Co-Design phase reporting participants’ ratings and experiences of communicative challenges in the different contexts of everyday-communication.

Conclusion and Discussion: The results of our Co-Design interviews will inform the further development of Commbi-FUNC and Commbi-PROM.

Background: Moderate to severe traumatic injuries, including traumatic brain injury, may lead to long-term impaired functioning and problems in daily life activities. A significant proportion of individuals who sustain such injuries report unmet healthcare needs in the first year post-injury. Self-management interventions can improve patient outcomes, but self-management support programs delivered during the sub-acute phase remain scarcely evaluated in this patient population.

Objectives: This study had two objectives: (1) to design a comprehensive self-management program (SEMPO) specifically tailored to individuals with traumatic injuries in the sub-acute phase, and (2) to describe the protocol of a pragmatic randomized controlled trial investigating the effect of the SEMPO program on patient outcomes. We anticipate that SEMPO will enhance self-efficacy in symptom management and prevent long-term impairments and disability.

Methods: The SEMPO program was developed, drawing from established self-management principles and evidence-based rehabilitation strategies, by experienced clinicians and researchers in collaboration with individuals with lived experience with traumatic injury and a national user organization. Effect of the program will be assessed in a randomized controlled trial with both an intervention and a control arm. An exploratory self-selection arm will be included to explore the influence of patients' preferences on treatment effect. The study will include 220 patients, aged 18-72 years admitted to the trauma referral center at Oslo University Hospital directly or within 72 hours with a moderate-severe traumatic injury (New Injury Severity Score > 9) and a minimum 2-day hospital stay. Patient-reported outcomes will be evaluated six months post-intervention, with paralleled time point for the control group. The primary outcome is levels of self-efficacy (the Trauma Coping Self-efficacy Scale), and secondary outcomes include somatic, emotional and cognitive symptom burden, physical functioning and disability, return to work, healthcare utilization, health-related quality of life, and health- and communication competency. Participants will nominate one domain-related measurement as their preferred outcome measure. Clinical Trias identifier: NCT06305819.

Results: The SEMPO program was finalized in April 2024 and consists of eight weekly 2.5-hour sessions delivered in groups of 4-7 participants, either face to face or as a tele-health version. The program incorporates several components, including psychoeducation, goal setting, action planning, practice in compensatory strategies, and problem-solving techniques. The group format facilitates the sharing of knowledge and experiences in management of injury-related consequences among participants, fostering social encouragement.

Conclusions: The development of a self-management support program aligns with a person-centered rehabilitation approach. It integrates the self-management concept into a manualized group-based intervention, specifically targeted at individuals with moderate to severe physical trauma, including traumatic brain injury. Moreover, the inclusion of a self-selection arm provides a unique opportunity to investigate the influence of patient preferences on the outcome effect and adherence to the SEMPO program.

2024-2025 updates to the guideline highlight the importance of returning to safe activities, including non-contact aerobic exercise and school while recovering from a concussion. Treatment from an interdisciplinary team is recommended for those not improving after two weeks and right away for those identified as at risk of a prolonged recovery. These updates have led to a paradigm shift in treatment approaches and updated return to activity, sports, and school protocols. Despite the benefits of these advancements, disseminating and implementing updated guidelines to everyone in the circle of care, including frontline healthcare professionals, families, youth, coaches, and teachers, remains a challenge. For example, many healthcare professionals only have access to outdated practice guidelines that suggest complete rest and recommend stopping an activity when symptoms worsen mildly.
To address this gap, our team is collaborating with the TRANSCENDENT Concussion research program’s Community Advisory Committee to develop knowledge translated resources aimed at improving guideline dissemination to frontline healthcare professionals, families, and youth. Our initial focus has been on creating an updated and accessible Family Version of the guideline, working alongside individuals with lived experience, community members, and clinical experts, in a co-creation collaborative design process. The goal of this approach is to ensure the resources created and shared are practical and relevant to the needs and priorities of those directly affected by concussions, with the goal of improving uptake.
The living nature of the guideline is an opportunity to continually improve concussion care practices as we learn more about how to treat and prevent this type of mild traumatic brain injury and ultimately improve outcomes. Ongoing collaborative efforts to close the gap between evidence and practice are essential so all individuals involved in pediatric concussion care have access to the latest evidence-based recommendations.

Somatic symptom disorder (SSD), a neuropsychiatric condition characterized by distress about physical symptoms, may be common following concussion but has not been previously investigated. In a secondary analysis of data from a cluster randomized trial (Clinicaltrials.gov #NCT04704037), we examined the prevalence, correlates, and functional impact of SSD after concussion.

Methods: 477 adults (44% male, M=39 years old, 61% White) were recruited from emergency departments and urgent care centres in the Greater Vancouver Area, Canada. Participants completed ratings of post-concussion symptoms (Rivermead Postconcussion Symptoms Questionnaire; RPQ), bodily pain (Brief Pain Questionnaire; BPQ), depression (Patient Health Questionniare-9; PHQ-9), anxiety (Generalized Anxiety Disorder-7; GAD-7), disability (World Health Organization Disability Assessment Schedule; WHODAS), and Criterion B symptoms of SSD (Somatic Symptom Disorder-12; SSD-12) at 6-months post-injury. SSD was operationalized as persistent symptoms that interfered with daily functioning and an SSD-12 total score >=16. Depression and anxiety disorder diagnoses at 6 months post-injury were derived from the Mini International Neuropsychiatric Interview for Diagnostic and Statistical Manual of Mental Disorders-5.

Results: At 6 months post-injury, 27.3% (n=130) of participants met our definition of SSD. Participants with SSD reported greater post-concussion symptoms (RPQ; W=4846, p<.0001), chronic pain (BPQ; W=7951, p<.0001), depression (PHQ-9; W=6755, p<.0001), and anxiety (GAD-7; W=7068, p<.0001) than those without SSD. Participants with SSD were also more likely to have comorbid Major Depressive Disorder (OR=9.11, 95% CI=5.27-16.22) and at least one anxiety disorder (OR=5.59, 95% CI=3.60-8.75). A generalized linear model including both post-concussion symptoms (RPQ) and SSD symptom severity (SSD-12) provided a better fit for predicting functional disability (WHODAS) than a model with RPQ alone (ΔDeviance=0.217, p<.0001). Both RPQ (b=0.013, SE=0.001, t=11.08, p<.0001) and SSD-12 (b=0.012, SE=0.002, t=7.26, p<.0001) were significant predictors.

Conclusions: People with SSD after concussion have a greater burden of global post-concussion symptoms, pain, and mood dysregulation, and are more likely to have a comorbid mood and/or anxiety disorder(s), compared to those without SSD. Maladaptive thoughts, feelings, and behaviors related to symptoms (i.e., Criterion B symptoms of SSD) may contribute to disability over and above symptom severity. Assessing for SSD in adults with persisting symptoms after concussion could help direct care to psychological distress, and in turn, improve functional outcomes.

Most mild traumatic brain injuries (mTBIs) are diagnosed based on patient history and/or subjective impressions, rather than objective clinical signs. Consequently, diagnostic accuracy for mTBI in emergency settings is often inadequate. Furthermore, physical examination measures for mTBI are not uniformly utilized, nor have they been accurately formulated based on objective studies. Current sports concussion exams are largely founded on either expert consensus (e.g., SCAT6) or the examiner's discretion.
An mTBI results in subtle damage to a diffuse network of neuronal connections involving the cortex, brainstem, cervical cord, and/or autonomic nervous system. This leads to abnormalities that cannot typically be localized to a specific lesion. Therefore, soft sign exams maybe a better way to assess these patients. The Physical and Neurological Examination of Soft Signs (PANESS), originally designed to detect developmental difficulties, has shown promise in detecting residual deficits in SRCs, relative to some of the current mTBI assessment exams. However, the PANESS was not originally designed for acquired traumatic pathology, such as SRCs.
In previous research, we demonstrated that the SME, a soft sign exam originally developed for high velocity mTBIs, revealed individuals with a mTBI displayed significantly more soft signs than healthy controls. This work also revealed that subconcussed athletes, in contact sports, generally displayed an increase in soft signs, on at least a temporary basis, following sport participation. In this study, we used the SME to determine the average number of soft signs in a healthy, never concussed, athletic female population and compared their results to those from their peers who had previously been concussed but had ‘recovered’.
The SME includes several visual, motor, balance, autonomic, and reflex tests that can be conducted at the bedside or sideline. To date, we have studied over 30 individuals. The average number of soft signs observed in the healthy population was 1.6, with a range of 0-3 and a standard deviation of 0.8. Individuals scoring above 3 soft signs were more than two standard deviations beyond the mean. In our mTBI population, the average soft sign score was 5.8, with a range of 3-10. Notably, the single concussed athlete who scored a 3 experienced only a single concussion more than two years prior to testing.
The SME shows promise as a standardized tool for assessing all mTBI patients, both SRC and high velocity injuries. The SME has the potential to improve diagnostic accuracy and guide treatment interventions. Furthermore, our preliminary data and past research suggest that the number of soft signs present in an individual is directly correlated with the number of concussions experienced and/or the forces involved in with their injury. Additionally, our sequential testing data, suggests that the rate of soft sign resolution may help predict outcomes.

Background: It is now well recognized that people experiencing homelessness are much more likely than the general population to have a history of acquired brain injury (ABI), whether traumatic or non-traumatic. Many recent studies show that most people experiencing homelessness have sustained a first ABI before their first episode of homelessness. This indicates a possibility and need for targeted homelessness prevention interventions after an ABI, particularly for individuals who present with prior psychosocial vulnerabilities. In light of this phenomenon and given the rapid increase in people experiencing homelessness in Québec (Canada), public officials identified the need for a knowledge synthesis on homelessness prevention for this population.

Methods: Our team conducted a rapid literature review to identify and characterize secondary and tertiary homelessness prevention interventions, using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist and Cochrane recommendations for rapid reviews. Two independent analysts applied the search strategy and conducted the study selection, data extraction, data analysis and synthesis, and quality assessment.

Results: We identified 2771 studies through the searches. Twenty articles were selected and analyzed. Eleven of these articles examined secondary homelessness prevention interventions in various settings: correctional and justice-related facilities (n=7), community or home settings (n=3), and physical rehabilitation settings (n=1). Secondary homelessness prevention interventions based in correctional and physical rehabilitation facilities have shown positive effects on housing status, functional status, engagement in productive activities, and access to services. Nine articles examined tertiary homelessness prevention interventions within community-based settings such as shelters, medical respite programs, urban health clinics, and intimate partner violence shelters. Tertiary homelessness prevention interventions show promising effects on functional status and access to services, although no longitudinal studies have been conducted to assess medium- or long-term effects on housing outcomes. Common features of homelessness prevention programs include screening for ABI in settings where prevalence of possible ABI is high, ABI-specific training for non-specialized staff in those settings, provision of direct services to service users and caregivers, particularly for behavioral challenges, and cross-sector partnerships and training.

Conclusions: Emerging data from this review show that it is possible, feasible, and promising to prevent homelessness after an ABI. The opportunities and challenges for adaptations of these homelessness prevention interventions in local contexts will be discussed.

Introduction: Pediatric concussion is common in early childhood (i.e. 0–5 years). However, most knowledge mobilization (KM) initiatives and studies primarily focus on children aged 6 years and older, especially within school settings, leaving a gap in tailored KM tools for younger children (Mallory et al., 2022; McKinlay & Buck, 2019). In this population, unique challenges exist due to the difficulties in self-reporting symptoms and the distinct symptom patterns associated with early childhood concussions (Dupont et al., 2022; 2023). Most children in this age group also spend a significant amount of time in formal childcare settings, necessitating appropriate tools for use by childcare educators.

Objective: This study is part of the COCO (COncussion COmmunication) KM Program, and aims to address the gap in early childhood concussion KM through two objectives: (1) explore childcare educators’ knowledge of early childhood concussion, and (2) develop a concussion detection tool specifically designed to meet their needs.

Methods: (1) The first phase of the study involved a survey administered to 28 educators in Quebec’s largest daycare center, assessing their experiences with head injuries, training and knowledge of concussions, and preferred methods for receiving information. (2) The second phase involved the development of a concussion detection tool through a collaborative, iterative approach, drawing on input from the survey, focus groups, pediatric emergency and traumatology health care professionals, literature, existing guidelines, and in-person training sessions. A total of 23 educators and 36 students in a childcare education program participated in these sessions, with post-training surveys completed by seven educators and all 36 students.

Reults: The resulting COCO Detection tool is a one-page decision aid designed to guide educators through the steps to take after witnessing a head injury in a young child. It includes a list of signs and symptoms, with corresponding levels of urgency and recommended actions. Out of the 43 individuals who completed post-training surveys, most (n=40, 93%) thought that they could use the COCO Detection tool in their future practice. All respondents (n=43, 100%) found the tool very or rather easy to use, and all students (n=37) considered it very or rather relevant.

Conclusions: Childcare educators frequently encounter head injuries but may not fully understand their potential impact or recognize them as concussions. The COCO Detection tool is a promising solution to empower educators to better identify and respond to possible concussions in young children. Future research should investigate factors that may enhance educators' confidence in using the tool, as well as the potential for broader applications beyond childcare educators, such as its adaptation for other early childhood professionals including day camp counsellors and healthcare professionals.

Family caregivers play an important role in the recovery and rehabilitation of stroke patients. Despite the substantial benefits their support provides to the patient, a lack of an integrated system to support holistic health delivery for stroke care puts an enormous burden on family caregivers as they navigate life with additional responsibilities imposed on them. Inadequate health infrastructure places patients and their caregivers in more desperate or helpless circumstances. Investigating the lived experiences of family caregivers of stroke patients via a qualitative study (phenomenological study design) presents one way of directly uncovering the progression and impacts of stroke on both patients and the family members who care for them. In addition to their experiences in general, this study focuses on family caregivers’ experiences with regards to post-stroke communication difficulties experienced by their family member. The study provides insights into care challenges and the support needed by family caregivers to advocate for adequate and sustainable support to them in the future.

Recent evidence suggests that athletes with a concussion history are at an increased risk of subsequent lower extremity musculoskeletal (LEMSK) injury. Research has also found a potential association between pre-season cognitive performance and injury risk. Whether cognitive performance mediates the relationship between concussion history and subsequent LEMSK has yet to be explored. In this study, we conducted regression and mediation analyses to examine this relationship. Secondary analyses re-ran the same models, but with history of multiple concussions as the predictor, rather than history of a single concussion.

The sample was elite/international-level athletes from a Canadian national sport institute. Pre-season cognitive performance was measured by a computerized battery (Vienna Test System) and included tests of reaction time, sustained attention, inhibition, working memory, and planning ability. Concussion history prior to cognitive testing was documented via self-report in a medical history interview with a sports medicine personnel. Subsequent LEMSK injuries were documented prospectively in an injury surveillance program. Regression models determined the relationships between concussion history and subsequent LEMSK, concussion history and cognitive performance, and cognitive performance and subsequent LEMSK, prior to conducting mediation analyses that examined whether cognition mediates the relationship between concussion history and subsequent LEMSK. The analyses will also be conducted for history of multiple concussions (0-1 previous concussions vs. 2+ concussions). All models controlled for sex and age as covariates.

The sample included 145 athletes (female = 86; mean age [SD] = 21.50 [4.05], age range: 14.42 to 35.58 years) across six different sports within the concussion management program: artistic swimming, boxing, diving, short-track speed skating, trampoline, and water polo. Concussion history and history of multiple concussions significantly predicted subsequent LEMSK (β = 0.83, p = 0.026; β = 1.18, p = 0.028). Concussion history was also significantly associated with increased errors on an inhibition test (β = 1.13, p = 0.046), faster reaction time on an inhibition test (β = -0.022, p = 0.005), and faster reaction time on a sustained attention task (β = -0.044, p = 0.025). History of multiple concussions was associated with faster detection time (β = -30.40, p = 0.0028). The only cognitive measure that significantly predicted subsequent LEMSK was slower reaction time on a working memory task (β = 2.45, p = 0.029). In mediation analyses, no cognitive measures mediated the relationship between concussion history (or history of multiple concussions) and subsequent LEMSK.

Identifying risk factors for LEMSK injuries is critical for injury prevention. We found that relationships exist between concussion history, pre-season cognitive performance, and subsequent LEMSK, but that cognition does not mediate the relationship between concussion history and subsequent LEMSK. Future research should continue to explore the exact mechanism underlying the relationship between concussion history and injury risk.

Introduction: Zolpidem is a non-benzodiazepine hypnotic agent commonly used for the treatment of insomnia. Initially administered to manage restlessness in severely brain-injured patients with disorders of consciousness (DoC), it elicited paradoxical consciousness-enhancing effects in ∼5-20% of these patients. Interestingly, similar paradoxical effects (e.g., inability to fall/stay asleep, higher levels of restlessness, agitation, concentration) have been observed in the general population, yet the prevalence rate remains unknown. This survey aims to investigate (1) the proportion and purpose of zolpidem use and the prevalence rate of zolpidem-induced paradoxical effects in the general population, (2) common paradoxical effects experienced by zolpidem users, (3) the onset time and duration of the paradoxical effects, and (4) factors predicting paradoxical responses to zolpidem.

Methods: In this cross-sectional epidemiological study, an anonymous survey was developed in English and French and distributed on Alchemer and Prolific Academic online platforms. The survey included dichotomous, multiple choice, and open questions on (1) sociodemographics (age, gender, country of residence), (2) medical history (medical conditions, neurological/psychiatric disorders, medications), and (3) zolpidem use (purpose, paradoxical effects, onset time and duration of the effects, dosage, subjective perception of the experience). Participants were recruited via (1) network (social media, mailing lists, and institutional websites) and (2) crowdsourcing (Prolific Academic) approaches. The inclusion criteria were set to ≥ 18yo and fluency in English or French. Data were cleaned in Excel and analyzed using RStudio.

Results: Overall, among 15,289 participants (mean age 32 ± 13yo; 52% female; from 84 countries), 781 (∼5%) reported to have used zolpidem at least once as a sleep-inducer (94%), recreational drug (7%), psychostimulant (3%), and other (4%; e.g., to reduce anxiety). Among these zolpidem users, 128 (∼16%) reported one or more of the following zolpidem-induced paradoxical effects: inability to fall asleep (59%), restlessness (42%), inability to stay asleep (35%), excitation (35%), agitation (26%), increased alertness (19%), increased energy (19%), increased concentration (10%), and other (10%) (e.g., euphoria, paranoia). Paradoxical effects emerged most commonly within the first hour (58%). Participants subjectively perceived these paradoxical effects as unpleasant (42%), annoying (41%), exhaustive (37%), pleasant (22%), exciting (12%), and other (6%) (e.g., embarrassed, anxious). Multivariate binary logistic regression analyses showed neurological/psychiatric disorders were significantly associated with the likelihood of paradoxical responses to zolpidem (LR Chisq = 6.39, df = 1, p< 0.05).

Conclusions: The ∼16% prevalence rate of zolpidem-induced paradoxical effects is comparable to what is observed in severely brain-injured patients with DoC. As the arousal/awareness-enhancing effects of zolpidem seem similar between the general population and patients with DoC, analogous mechanisms might be underlying these effects. Further studies with multimodal approaches (e.g., neurophysiological, genetic) are warranted to investigate the mechanisms underlying zolpidem paradoxical effects both in DoC patients and in the general population.

Background: Guidelines for concussion management recommend a multimodal approach to assessing readiness for return-to-play (RtoP) including symptoms, balance, exertion, and cognition. However, existing assessments do not reflect the speed or complexity of multidomain skill integration in sport. We previously established proof-of-concept for R2Play, a dynamic multidomain RtoP assessment tool, among healthy youth by demonstrating alignment with initial design objectives.

Objectives: (1) Assess the feasibility of R2Play in youth with a history of concussion; (2) Examine youths’ physical exertion during R2Play as a preliminary marker of face validity; (3) Understand clinician and youth perspectives on the feasibility, face validity, utility, and challenges associated with R2Play.

Methods: Convergent parallel mixed methods design. Clinicians were paired with youth with a history of concussion to complete R2Play together and provide feedback through individual semi-structured interviews. Feasibility was assessed based on usability (clinician ratings on System Usability Scale, observable user errors), reliability (technical issues), practicality (clinician training evaluation, R2Play assessment duration), and safety (symptom exacerbation, adverse events). Exertion was evaluated against a target of youth achieving ≥ 80% of age-predicted maximal heart rate or rating of perceived exertion ≥ 7/10. Interviews explored perspectives on feasibility domains and face validity and were analyzed using content analysis. Quantitative and qualitative results were merged via joint display to identify areas of convergence, divergence, and complementarity.

Results: Participants included 10 youth (ages 13-20 years) with diverse sport experiences and five clinicians (n= 2 physiotherapists, n= 2 occupational therapists, n= 1 kinesiologist). Success criteria were met or approached for all feasibility domains. Clinician-rated usability was good-to-excellent (SUS= 84.00± 6.02) and youth reported that instructions were easy to learn. There were no user or technical errors causing assessment cessation. Assessments were configured in 5.74± 1.09 minutes and completed in 26.50± 6.02 minutes. There were no safety incidents or symptom exacerbation requiring assessment modification or cessation. R2Play elicited vigorous intensity physical exertion (peak HR= 90.10± 5.78% age-predicted maximal, peak RPE= 5.50± 1.72), with target exertion criteria met for 9/10 youth. Clinicians and youth discussed how R2Play reflects key elements of sport across physical, cognitive, and perceptual domains, making it a potentially valuable tool for assessing readiness to RtoP and informing rehabilitation treatment planning post-concussion. Mixed methods meta-inferences provided enhanced insights regarding how to improve the usability, practicality, safety and face validity of R2Play.

Conclusions: Findings support the preliminary feasibility and face validity of R2Play, a new multidomain RtoP assessment tool for concussion, with excellent usability, vigorous physical exertion requirements, and promising feedback regarding its potential to fill gaps in the RtoP process. An ongoing multicenter study aims to establish the cross-site feasibility of R2Play and evaluate its face and content validity by demonstrating the physical, cognitive, and perceptual loading of assessment levels.

Accurately identifying mental health symptoms in student-athletes is critical for delivering timely and appropriate care. Previous research has demonstrated that 1 in 3 college students experience significant anxiety and depression symptoms (Adams et al., 2021). Among student-athletes, anxiety affects 30% of women and 25% of men; however, only 10% seek help (ACSM, 2021). The NCAA's 2020 well-being survey reported that rates of anxiety, depression, and mental exhaustion among athletes have increased 1.5-2x compared to pre-COVID-19 levels (NCAA, 2022), emphasizing the increasing severity. These findings highlight the growing mental health burden on student-athletes and identify the need for practical screening tools. Baseline concussion testing, such as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), could serve as a valuable tool for identifying athletes at risk for anxiety and depression. This study investigates the utility of ImPACT as a mental health screening tool. The sample included 601 varsity and club college athletes from a mid-sized university in the Southeast region of the US (47.3% female; 16% ADHD). Symptom clusters, a grouping of related symptoms that help categorize and assess an individual's mental health, were evaluated using the ImPACT tool. Affective symptoms included nervousness and sadness; sleep symptoms captured disruptions in sleep patterns; cognitive symptoms assessed difficulty concentrating and feeling mentally foggy; and physical symptoms included headaches and dizziness. Anxiety levels were measured using the Generalized Anxiety Disorder-7 (GAD-7) scale, and depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Regression analyses were conducted that examined symptom clusters to predict anxiety and depression. Gender and ADHD were also evaluated as potential predictors in these analyses. Of the athletes, 49.5% reported no depression, 14.8% had mild depression, 12.4% had moderate depression, and 6.2% experienced severe depression. For anxiety, 55.3% reported no anxiety, 13.1% experienced mild anxiety, 8.4% had moderate anxiety, and 6.7% had severe anxiety. Hierarchical regression analyses revealed that gender and ADHD explained a small but significant portion of the variance in depression (R²change = .029, p < .001). The affective (R²change = .226, p < .001), sleep (R²change = .040, p < .001), and cognitive clusters (R²change = .018, p < .001) contributed substantially to the overall variance (31.2%). Similarly, the model for anxiety explained 29.4% of the variance, with significant contributions from ADHD, gender (R²change = .035, p < .001), and the affective cluster (R²change = .259, p < .001). These results suggest that ImPACT concussion symptom scores may serve as a practical preemptive screening tool for anxiety and depression in collegiate athletes. Integrating mental health evaluations into concussion protocols could provide and improve timely interventions and support for the psychological well-being of student-athletes.

Background: Paroxysmal Sympathetic Hyperactivity (PSH) presents a significant challenge in managing Acquired Brain Injury (ABI), marked by unpredictable autonomic responses. This study leverages Heart Rate Variability (HRV) and machine learning to predict early autonomic changes before PSH episodes.

Methods: Four ABI patients, diagnosed with PSH using PSH-Assessment Measure (PSH-AM) scores, were continuously monitored using an FDA-approved ECG device (BioPatch - Zephyr Technology). The cohort included three Unresponsive Wakefulness Syndrome/Vegetative State (UWS/VS) patients with hemorrhagic, cardiac arrest, and traumatic brain injury etiologies, and one Minimally Conscious State (MCS) patient with hemorrhage. Fourteen PSH events were monitored. HRV metrics included SDNN, RMSSD, LF, HF, and VLF, alongside Multiscale Entropy (MSE) analysis to compute short- and long-scale Complexity Indices. A Support Vector Machine (SVM) classifier was trained to differentiate PSH from tachycardia (TCH).

Results: Significant increases in heart rate from 72 ± 5 bpm to 115 ± 10 bpm (p < 0.01) were observed before PSH episodes. While no significant changes in the LF/HF ratio were noted during or between PSH and TCH events, the VLF/(LF+HF) ratio significantly increased during PSH (p < 0.05), distinguishing it from TCH. Notably, the SVM classifier achieved 100% accuracy in predicting PSH events 10 and 20 minutes before their onset. This indicates that early detection is possible, with VLF and complexity indices being critical predictive biomarkers. Overall, the classifier achieved 93% accuracy in distinguishing PSH from tachycardia.

Conclusions: HRV analysis, particularly the VLF component and complexity indices, combined with machine learning, demonstrates a robust ability to distinguish PSH from tachycardia events not only during the episodes but also up to 20 minutes before their onset. This early differentiation can guide more timely interventions, improving clinical management of PSH in ABI patients. While this approach cannot predict PSH occurrence in advance based solely on HRV, it offers valuable insights into distinguishing these critical events from other autonomic dysfunctions. Further validation with larger patient cohorts is necessary to integrate this method into clinical practice.

Background: Traumatic brain injuries (TBI) often have a long-term impact on an individual’s cognitive communication ability, affecting social interactions and relationships. This can be most evident in spoken discourse. Discourse assessments are recognised as critical to evaluate both the monologic and conversational levels of communication. Stakeholder perspectives on clinical materials have been explored in a range of areas of speech-language pathology (SLP) practice (e.g., post-stroke aphasia) and are key to the future development of SLP assessment and intervention resources; however, the views of people with TBI on currently used elicitation materials have not been examined. This research aimed to understand stakeholder perspectives on various narrative discourse stimuli, with the aim of informing and supporting clinical practice for communication post-TBI.

Methods: A mixed-method approach was utilised in this pilot study, with face-to-face semi-structured interviews, and rating and ranking scales. Participants were asked to complete eight narrative discourse elicitation tasks. Stimuli included single pictures (e.g. the Cookie Theft), picture sequences, a wordless picture book (Cinderella story), and a short video. This was followed by an interview seeking their views and preferences around these tasks. Questions explored participants' engagement, interest and preferences of the visual tools used in the assessment. A thematic framework approach was taken for the analysis of data. Participants ranked the tasks in order of preference and used a rating scale to rate each individual task.

Results: Two participants with cognitive communication disorder after severe TBI discussed their views on individual tasks, and ranked these, providing an understanding of their preferences. Participants rated picture sequences, a wordless picture book and video formats highly, noting that the progression over time and the format of both the video and the longer story supported the narrative elicitation. Participants also identified that this led to more engagement in the task. Key areas discussed included ease of understanding; format of the presented visual; and engagement. Distinctions were made between video, single and multiple image sequences; black and white or colour images; and the impact this had on both understanding and story generation.

Conclusions: Narrative discourse elicitation tasks are a beneficial way to assess and analyse discourse in individuals post TBI, fulfilling a key area within the assessment battery. Stakeholder perspectives provided an understanding of the level of engagement and interest in the tools used during these assessments. Participants identified video format and picture sequences as being most engaging. They also discussed their views on content preference, ease of understanding and interests. Findings from this preliminary research add to limited evidence on the types of visuals that are most engaging and why. Future research is needed to explore the impact of engagement on discourse production measures and further development of visual stimuli for discourse elicitation.

BACKGROUND: Concussions are common, and a substantial proportion of people experience persistent symptoms. Persistent postconcussion symptoms (PPCS) interfere with people's work- and social life and are associated with lower health-related quality of life. Symptom complexity is a challenge in diagnostics and treatment of the condition. A mobile health application (mHealth app) may be an accessible tool for symptom mapping and facilitating symptom management for people with PPCS. OBJECTIVE: To develop a research-based mobile application for personalized symptom mapping for people with PPCS and investigate its usability and safety. METHODS: This development- and usability study consisted of three iterative cycles each containing: a) app usability evaluation by a user group, b) app review by a clinician group, and c) app designing and programming. The user group attended 2-hour usability testing sessions in a hospital setting in the first two cycles. In the third cycle, they conducted a 4-week home testing. The clinician group attended 1-hour app reviews in their work environments in all cycles. Usability was measured using the mHealth App Usability Questionnaire for the user group (7-point Likert scale) and the Mobile App Rating Scale for the clinicians group (5-point Likert scale). Qualitative interviews further informed the development process in all cycles. Safety was evaluated based on the frequency of adverse and serious adverse events during the study period. RESULTS: Twenty-three adults (age 21-69, 80% females) with PPCS were included in a user group, and six clinicians (mean age 49, 50% females), with a mean of 13 years of work experience with people with PPCS, were included in a clinician group. The user group had a mean score of 5.0 on the mHealth App Usability Questionnaire and the clinician group had a mean score of 4.1 on the Mobile App Rating Scale. The qualitative interviews provided important insight for the development and improvement of the app, and the study revealed challenges with technical implementation that should be mitigated in future versions for enhanced user experience. Two adverse events related to increased awareness of symptoms were logged during the home testing. No severe adverse events were logged during the study period. CONCLUSION: We developed an mHealth application for symptom mapping for people with PPCS based on feedback from users and clinicians in an extensive iterative development process. The app generally received high usability scores from both the user and clinician groups, and it is safe to use for its intended purpose. The mHealth application is an acceptable tool for symptom mapping, and the effect on symptom management and possible side effects should be further investigated in a larger clinical trial.

Background: A Montreal-based interdisciplinary rehabilitation traumatic brain injury (TBI) program developed a 12-week group-based physical activity intervention (120 minutes per week) for adults having difficulties resuming daily physical activities (3 to 18 months post injury) while managing their symptoms (headache, sensitivity to light, dizziness). Using an approach based on motivational interviewing and educational capsules, the program aimed to improve participants’ general physical condition by helping each participant identify a meaningful physical activity (PA) and learn to gradually increase the amount of this activity to tolerable symptoms. The kinesiologists and physiotherapists established a standardized evaluation procedure to help identify the most appropriate measures for assessing progress and intervention impact.

Objectives: to determine whether measuring patient progress was feasible and whether the chosen tools could detect functional change.

Methods: Program members selected four reliable and valid clinical tools with minimal administrative burden to assess functional endurance (6 Minute Walk Test -6MWT: minimal clinically important difference (MCID) = 54-80 meters), muscle endurance (Arm curl test and Sit to Stand Test-StoS MCID=2 reps), and fear of movement or re-injury (Tampa Scale for Kinesiophobia – TSK) and collected data for each measure for 73 consecutively admitted participants over a 4-year period. Data were analyzed pre- and post-intervention using paired t-tests (p < 0.05).

Results: Tests were often difficult to administer routinely due to time and human resource constraints, COVID-19, and uncompleted questionnaires. For example, no data could be obtained from 22 participants (30%) due to COVID-19 and program dropouts; partial data were obtained for 51 participants. Seven (9.5 %) participants performed the Arm curl test, and this measure was later abandoned due to lack of pertinence. Pre and post measurement data were obtained for 14 participants for the remaining 3 tools and 27 participants had data for 2 tools (StoS and 6MWT). The results showed significant improvements across all 3 measures despite small sample sizes. In the 6MWT, participants' distances increased on average by 42 m (n=27; p=0.003), while the number of repetitions in the StoS test also rose on average by 3.11 repetitions (p = <0.001). Additionally, there was a reduction in kinesiophobia, indicated by lower TSK scores (n=14, p = 0.017). Despite the overall positive outcomes, 4 participants did not show improvement in the 6MWT, 4 in the StoS test, and 3 in the TSK.

Conclusions: Although the results are limited to one sample, this exercise allowed clinicians to reevaluate and optimize their intervention and to select appropriate tools adapted to their clinical setting allowing them to continue to monitor participant progress. These findings also highlight the variability in individual responses to the PA intervention, suggesting the continued need for individually tailored approaches for all.

Introduction: Recovering Concussion Update on Progression of Symptoms (ReCoUPS) is a novel mobile ecological momentary assessment platform protocol which monitors concussion symptoms remotely and in real time. The purpose of this study was to determine the feasibility of monitoring post-concussion symptoms and Psychological Health-Related Quality of Life (PHRQoL), and the fluctuations in these outcomes, using ReCoUPS throughout concussion recovery.

Methods: We enrolled 17 college-aged athletes with a concussion (female=11, μ age=20.73±1.15 years) in our pilot study. Demographics, injury information, and enrollment in the ReCoUPS platform with a smartphone were completed within 3 days after injury. Thirty survey questions (i.e., Sport Concussion Assessment Tool6 (SCAT-6) symptom checklist, Patient Reported Outcomes Measurement Information System Emotional Distress Shorts Forms Anxiety and Depression [PROMISAnx and PROMISDepress]), were administered daily throughout concussion recovery via ReCoUPS text messages. Surveys were terminated within 2 days after full medical clearance and recalled PHRQoL inventories (i.e., “within the past 7 days”) were completed. Response rates (frequencies, %) for completed daily surveys were calculated. Cronbach’s alpha (α) determined internal consistency of daily momentary PHRQoL (mPHRQoL). Independent linear mixed-effects models estimated the within-person and between-person variance in symptom clusters and PHRQoL with intraclass correlation coefficients (ICCs) to determine the percentage of variability due to between-person differences.

Results: Over half (58.8%) of the participants completed more than 70% of daily surveys, while 82.4% completed over 60% of daily surveys (median days enrolled=12; IQR(1,3)=8,15). There was strong internal consistency among all mPHRQoL items (PROMISAnx α=0.88; PROMISDepress α=0.92). The average total symptom score throughout concussion recovery was 15.26 with standard deviations ranging from 0 to 32.04, indicating variability among participants. The mixed-effects models indicated that the between-person (BP) and within-person (WP) variances were significant contributors to the variation in affective symptoms (BP=4.93(SE=1.99); WP=8.08(SE=0.96); ICC=0.38; p<0.001), cognitive-ocular symptoms (BP=2.81(SE=1.15); WP=5.42(SE=0.0.64); ICC=0.34; p<0.001), migraine symptoms (BP=9.27(SE=4.44); WP=24.10(SE=2.89); ICC=0.28; p<0.001), total symptoms (BP=118.52(SE=51.62); WP=225.21(SE=26.88); ICC=0.35; p<0.001), PROMISAnx scores (BP=2.80(SE=1.08); WP=3.84(SE=0.46); ICC=0.42; p<0.001) and PROMISDepress scores (BP=1.62(SE=0.61); WP=2.12(SE=0.25); ICC=0.53; p<0.001) daily throughout concussion recovery.

Conclusions: Results from this pilot study indicate that ReCoUPS may be a feasible method of monitoring post-concussion symptoms and PHRQoL throughout concussion recovery, while the PROMISAnx and PROMISDepress may be reliable instruments for measuring these outcomes. Further, there may be meaningful differences in post-concussion symptom scores and PHRQoL between individuals, indicating that some athletes may consistently report higher or lower symptoms than others. Additionally, fluctuations in symptom scores and PHRQoL over time within the same individual were observed, indicating that athletes’ symptoms were changing daily throughout concussion recovery. With a larger sample size, we can continue to explore the acceptability, feasibility, and usability of ReCoUPS for future clinical implementation of remote post-concussion symptom monitoring and improved concussion management protocols.

Introduction: Brain-injured patients emerging from hyporesponsive syndromes, such as coma and the minimally conscious state, often show cognitive disturbance on multiple domains combined with waxing and waning arousal. This phase has various aliases, such as Post-Traumatic Amnesia, (Post-Traumatic/ Acute) Confusional State and Delirium. We seek to determine which term is most likely to be adapted throughout the chain of care for acquired brain injury patients and to promote better understanding and management.

Person Experience: Hella, 18 years of age, on a particularly stressful time during her rehabilitation following subarachnoid hemorrhage: ‘I remember waking up in a hospital bed without understanding the space or time I was in. In order to get a grip on things, I tried to recall usual stuff, such as my phone number – which I remembered – my address – which I remembered too – but I got stuck when I tried to recall my age. I was sure I had passed the age of 17, but also that that happened quite some time ago. I just lost it. The nurse didn’t know my date of birth from heart, and it dawned on me: my mother wasn’t here, these people didn’t really know me – I was not in good hands. Over the next weeks, I was cared for by nurses who seemed to know me while I felt I saw them for the first time. I was in tears regularly because my mother hadn’t visited me for weeks, even though she came by every day. Memory loss and confusion on this level cause such deep loneliness, as when the people close to you leave the room, their visit often doesn’t leave a lasting, or any, impression’.

Discussion: Multi-domain cognitive disturbance combined with fluctuating arousal is a transient, but impactful sequela of acquired injury. Swift recognition is crucial for treatment improvement and epidemiologic and pathophysiologic research (quoting soccer player Johan Cruijff: ‘You have to notice it before you see it’). The use of different terms for this condition hampers its identification as a clinical and scientific target. Adjectives concerning etiology (‘post-traumatic’) incorrectly suggest the condition is unique to specific mechanisms of brain injury. The term ‘post-traumatic amnesia’ should no longer be used as patients invariably display disturbances on different cognitive domains as well as behavioral symptoms. Diagnostic criteria for the terms ‘delirium’ (preferred term according to AAN and 9 other significant medicoscientific societies) and ‘confusional state’ (arising from the field of expertise on prolonged disorders of consciousness) are virtually identical. ‘Delirium’ may steer clinicians towards the prescription of antipsychotic drugs. The international brain injury community should adapt the term ‘confusional state’ and implement its use throughout the chain of brain injury care.

Introduction: A significant proportion of patients surviving severe brain injury needs 24-hour care for the rest of their lives. Not being able to live independently anymore is a worst-case scenario for many healthy people. But for patients with acquired brain injury (ABI) and their loved-ones, life goes on, even when it’s no longer within the familiarity and comfort of one’s own home. People with ABI may mourn what they have lost through their injuries, or feel stuck with their impairments, but they also continue to enjoy things, to have hopes and dreams. ABI patients tend to be much younger than the average nursing home population and may have decades ahead of them. Decades they, like any other person, want to fill with a meaningful, pleasurable life.

Challenge: In this universal aspiration, a major challenge is brought forth by the high prevalence of neuropsychiatric symptoms (NPS) after ABI. NPS, such as apathy, disinhibition, irritability, depression, anxiety and aggression, may be more likely to manifest after hospital discharge than during the initial admission. Symptoms may be persistent and even worsen over time. Caregiver burden increases significantly with cognitive dysfunction, behavioral symptoms, and impaired functional status of patients. NPS have a negative impact on the quality of life of people with ABI. But until now, little is known about which symptoms affect quality of life in what way. A complicating factor is that quality of life instruments often rely on self-reporting and communication skills which not all people with ABI are having any more. This means that gaining insight into the interaction between neuropsychiatric symptoms and quality of life of people with ABI is not easy to investigate. LIFE GOES ON
‘Life Goes On’ is a mixed-methods study on wellbeing in patients with ABI, and how this relates to their neuropsychiatric symptoms. In addition to established, quantitative scales, Life Goes On will invite ABI patients living in various kinds of health care institutions and their proxies to talk about their views on quality of life in a more inclusive way. The knowledge gained in Life Goes On will allow patients’ voices to lead future care program development, so that ABI patients and their loved-ones can enjoy more evidence-based, personalized care in the near future.

Approach: Quantitative analysis of an existing database on NPS and QOL with semi-structured interviews about established quality of life domains; Participants: patients <65 years of age with ABI in nursing homes and other long term care facilities within the Netherlands, and their representatives; Output: multi-domain insight into the relation between quality of life and NPS in ABI patients in long-term care facilities, to be used to improve wellbeing for patients in the near future in both care and policy

Patients with Prolonged Disorders of Consciousness (PDoC), lasting ≥ 28 days, often exhibit preserved movements after emerging from a coma. However, whether these movements are reflexive/patterned or intended actions remains unclear, raising critical questions about the presence of awareness of the self and the environment in these individuals, and creating emotionally difficult situations for their caregivers. Conventional behavioral assessments alone cannot accurately classify these movements, as they may appear reflexive or patterned to the naked eye, despite potentially being intentional. In contrast, existing approaches based solely on neuroimaging (e.g., EEG and fMRI) focus exclusively on brain dynamics, neglecting behavioral data.

Methods: Therefore, to classify these movements, this study employs a multimodal approach integrating both behavioral and electrophysiological data. We employ body gesture tracking (joint movement in upper limbs and face gestures) through a camera and MediaPipe software, alongside high-density (128-electrode) electroencephalography (EEG), galvanic skin response (GSR), and heart rate variability (HRV). High-density EEG is used to examine the temporal dynamics of the Dorsal Attention Network (DAT), which is believed to be associated with goal-directed attention. GSR and HRV are used as indicators of arousal.

Experiment: The “Hear Me” experiment involves three phases: resting state, passive listening, and active listening, during which all sensors collect data. In the passive phase, patients listen to music without interaction. During active listening, they can regulate the presence or absence of music through body gestures (e.g., hand movements and eye blinks).

Hypotheses: 1) DAT will be activated only when there is an intent to interact with the music. 2) The overall GSR and HRV activity will be elevated during the active phase compared to the passive phase if the patients are engaged in the task.

Conclusions: This experiment aims to identify goal-oriented gestures and potentially reveal covert consciousness during patients’ engagement with the music. By integrating behavioral and physiological data, this multimodal approach offers deeper insights into the nature of patient movements through the detection of arousal and conscious awareness in PDoC. We believe that the findings from this study could improve the assessment of the state of consciousness in PDoC and pave the way for Brain-Computer Interfaces (BCIs) that enable communication with them.

Background: The Netherlands have the lowest prevalence of prolonged disorders of consciousness (such as the unresponsive wakefulness syndrome and the minimally conscious state) reported worldwide. This is thought to reflect the specific Dutch ethical context in which treatment decisions in brain injured patients are made. Since the 1990s, physicians here have been allowed to discontinue life-sustaining treatment, including artificial nutrition and hydration, in patients with prolonged disorders of consciousness. In some cases, formally they can even be considered to be obliged to do so, specifically if a patient has no chance of recovery of consciousness or if he or she is presumed not to have given their consent for the continuation of treatment, were they able to communicate their wishes. However, even in this context some patients are treated way beyond the timeframe in which recovery is expected, sometimes against their presumed wish. In this study, we interviewed physicians on their reasons to do so.

Methods: semi-structured interviews with physicians of patients with CRS-R based diagnoses of unresponsive wakefulness syndrome at a mean of 14 years after injury, starting with the question: ‘what factors influence or influenced your medical treatment and decision-making in this specific case?’; qualitative analysis using Atlas.ti.

Results: 10 physicians (all elderly care physicians working in nursing homes), responsible for 9 patients, were interviewed. The patients’ family’s wish to have life-sustaining treatment continued was decisive in all cases and overruled factors such as diagnosis, prognosis and patient perspective. Physicians focused on their relation with the family, steering away from conflict. No external expertise was involved. The physicians considered themselves responsible for continuing life-sustaining treatment and took on a wait-and-see approach with regards to advance care planning even though this in their opinion resulted in an insufficient quality of life for their patient – a mean score of 1.6 on a scale from 0 (worst quality of life) to 10 (best quality of life). They all stated that they would not want to be treated the way they treated or had treated their patient. The weight of the family’s standpoint became clearest from the answers to the question what they would do if the patient had no family. Without exception, the answer was that in that scenario the physicians would discontinue life-sustaining treatment.

Conclusions: Physicians may continue life-sustaining treatment in patients with prolonged disorders of consciousness for decades, even if chances of recovery are considered negligible, the patient would presumable not give consent for the treatment they receive, and continuation goes against professional standards. The patient’s family is considered decisive in these cases, with physicians focusing on maintaining a good relationship with them while giving the patient’s perspective or presumed wishes no relevant position in the treatment plan.

Background: Cognitive communication disorders (CCDs) are common after acquired brain injury (ABI) and may negatively affect quality of life. Unfortunately, CCDs often go unnoticed and hence individuals often remain undertreated. Although the assessment of CCDs after ABI is thus of great importance, there is a lack of Dutch scientifically validated measurement instruments for assessing CCDs after ABI. Therefore, translation and cross-cultural adaptation of available measurement instruments that are designed for this purpose is highly needed. The La Trobe Communication Questionnaire (LCQ) has been specifically designed to measure perceived communicative ability after ABI from the perspective of individuals with ABI and close-others. To date, no version of this questionnaire is available for use in the Dutch population.


Objectives: To translate and cross-culturally adapt the LCQ into Dutch language, to pretest the Dutch prefinal version in individuals with ABI and close-others and to evaluate the content validity of the LCQ.


Methods: The LCQ was translated into Dutch following international guidelines, including forward- and backward translations. The prefinal version of the Dutch LCQ was then cognitively pretested in a sample of 7 individuals with ABI and 8 close-others in accordance with the WHO guidelines (Process of translation and adaptation of instruments) and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) for the evaluation of content validity of Patient-Reported Outcome Measurements (PROMS). During the semi structured interviews, participants filled out the questionnaire and answered questions about the comprehensibility of the instructions, response options and about each individual item of the questionnaire. In addition, participants rated comprehensiveness of the questionnaire on a 5-point Likert scale, as well as the relevance of each individual item for the construct, population and context of use.


Results: All individuals with ABI and close-others were able to fill out the LCQ independently. At first glance, participants overall reported the Dutch LCQ to be comprehensive and relevant. Several suggestions for improving the comprehensibility of some items were provided.


Conclusions: Results of this study will provide information on proposed adjustments and final revisions that have been made to finalize the Dutch version of the LCQ, as well as on the content validity of the LCQ. As final analyses are currently being performed, the final and official version of the Dutch LCQ is expected to be available at the end of 2024.

Background: An estimated 20-30% of people who sustain mild traumatic brain injury (mTBI) experience persistent symptoms requiring neurorehabilitation. This rehabilitation often focuses on reduction of impairment and improvement in abilities with the ultimate aim of increasing meaningful participation in desired activities. Changes in participation may be measured through self-report, either using published tools or procedures. This study investigated alignment between participation described by a standardized self-reported measure and person-centered goals elicited through motivational interviewing in military service members and Veterans (SM/Vs) with mTBI.

Methods: In this retrospective chart review study participation data were extracted from medical records of 94 SM/Vs with a history of persistent mTBI symptoms (injury onset at least 6 months prior). Primary outcomes were domain scores from the Participation Assessment with Recombined Tools – Objective (PART-O) and person-centered goals elicited through motivational interviewing administered at the time of evaluation for admission to an interdisciplinary intensive outpatient rehabilitation program. Each participant could have up to three goals. Goals were coded deductively into PART-O domains of productivity, out and about, and social relations. Two members of the study team first separately coded the goals and conflicts were resolved through consensus discussion with a third rater. A linear regression controlling for demographic and injury factors was used to examine the relationship between PART-O domains and person-centered goals.

Results: Participants reported the greatest frequency of participation in the Social Relations PART-O domain score (M = 2.58, SD = 0.84) followed by Productivity (M = 1.95, SD = 1.00) and then Out and About (M = 1.35, SD = 0.62) domain scores. PART-O domains were represented on half (50%) of the 191 person-centered goals set by participants, although three quarters of participants (74%) set at least one goal that could be coded into one of the PART-O domains. The Productivity domain was represented in 18.85% of the goals, Out and About was represented in 10.99% and Social Relations was represented in 19.90%. PART-O domain scores at program admission did not predict person-centered goal categories. Standardized coefficients ranged from -0.29 to 0.12 with no p value less than 0.12 and all confidence intervals included 0.

Conclusions: Participation is important to military SM/Vs with persistent mTBI symptoms but is difficult to measure and may vary greatly across individuals. Results here suggest that convergent methods to understand current participation and desire for change are necessary to guide neurorehabilitation. In particular, evaluating person-centered goals adjunctively when interpreting participation scores derived from standardized measures may add deeper context and support holistic models of care that promote meaningful participation outcomes.

Introduction: Traumatic brain injury (TBI) can impact various aspects of an individual’s life. Individuals with TBI often have complex healthcare needs both in the acute and long-term stages of their injury. As individuals with TBI are navigating through life after the injury, community integration is often a priority to improve quality of life. However, there is little known about the long-term experiences of community integration after TBI.

Objective: To explore the perceptions and experiences of community integration for individuals living with TBI in the community.

Method: This qualitative study used a descriptive phenomenological approach. Data was obtained from focus groups, comprised from a larger mixed-methods study. Participants were recruited through convenience sampling in British Columbia, Canada, and included if they were adults with TBI. A semi-structured interview guide on factors affecting individuals with TBI was developed in collaboration with patient partners with lived experience of TBI. Interviews were conducted with four focus groups, comprising of three to four individuals, online via Zoom. These interviews were audio- and video-recorded, and transcribed verbatim. Data were analyzed using codebook thematic analysis, and multiple investigators were involved in the data analysis process.

Results: Participants included 13 adults with TBI, between the ages of 25 and 64, who sustained their injuries between 1 and more than 20 years ago. Experiences of community integration were illustrated through three themes relating to employment or productive activity, independent living, and social activity: (1) ‘Am I left on my own?’ explored the support systems available after TBI, (2) ‘One size fits all’ described the response of society to TBI, and (3) ‘Adapting to a new normal’ highlighted the response of participants to a changed reality.

Conclusion: Understanding the long-term perceptions and experiences of community integration after TBI can improve public awareness and education to facilitate community integration, through acceptance and understanding. In addition, such perceptions and experiences may inform interventions that help improve the quality of life of individuals with TBI who are living in the community.

Introduction: Conventional clinical instruments for evaluating upper limb motor function may have a limited ability to detect subtle motor changes, which can be crucial for tracking recovery progress. These traditional tools may also introduce subjectivity, which can potentially alter the results. In contrast, kinematic assessments provide detailed, objective measurements of movement quality and quantity, which can complement conventional instruments and improve the evaluation of motor function. However, such assessments typically require expensive, complex equipment and time-consuming procedures, making them less practical for widespread clinical use. This study explores the potential of a cost-effective, touchscreen-based kinematic assessment tool to overcome these limitations by examining its reliability and validity in assessing upper limb function in post-stroke individuals. The goal is to offer a more accessible, accurate method for clinicians to track motor recovery.

Methods: In this study, sixty-four post-stroke patients were recruited. Each participant performed a visually guided reaching task on a large touchscreen, embedded in a conventional table. The task involved reaching from a central target to five peripheral targets arranged in a circular pattern, one at a time, and returning to the central target after each reach. To assess motor function, participants completed the Fugl-Meyer Assessment for Upper Extremity, the Box and Block Test, and the Nine Hole Peg Test. Kinematic measures of the movement trajectories recorded during the touchscreen task were analysed to assess both the reliability of the tool and its convergent validity by comparing it with the clinical instruments.

Results: The kinematic measures demonstrated strong test-retest reliability, with intraclass correlation coefficients showing moderate to excellent consistency across repeated measures. Convergent validity analyses revealed several significant correlations between the kinematic parameters and clinical assessments, particularly in tasks requiring higher levels of motor skill and precision. Notably, strong correlations were observed between the kinematic data and the Coordination and Speed subscale of the Fugl-Meyer Assessment for Upper Extremity, as well as the Nine Hole Peg Test, which highlight the sensitivity of the kinematic assessment in capturing fine motor control and functional performance.

Conclusions: The touchscreen-based kinematic assessment proved to be a cost-effective, reliable, valid, and sensitive tool for evaluating upper limb motor function in stroke survivors. Its ability to provide detailed, objective insights into movement quality could potentially enhance conventional clinical assessments. Furthermore, the affordability, ease of use, and fast operation of the instrument could facilitate its widespread clinical adoption, offering a scalable approach to better monitor and track motor recovery in stroke patients.

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