Background: Participation in sports increases the risk of sustaining a mild traumatic brain injury (mTBI) also known as sports-related concussion (SRC) (Dioso et al., 2022). One-third of collegiate athletes report experiencing a concussion in their lifetime, with 20% having more than three (Veliz et al., 2019). SRCs are associated with transient-to-long-term cognitive and emotional difficulties. We examined executive functioning and emotion regulation for athletes with self-reported mTBI/SRC relative to athletes without TBI history. Emotion regulation has been understudied, though collegiate athletes with affective symptoms tend to have delayed recovery and return-to-play following SRC.

Methods: A cross-sectional, between-groups design with collegiate athletes recruited from universities in Western New York. Neuropsychological tests of general cognitive and executive function (Test of Premorbid Function, WAIS-IV: Digit Span, Matrix Reasoning, Vocabulary, Letter-Number Sequencing; Delis-Kaplan Executive Function System (DKEFS): Trail Making Test, Verbal Fluency, Color Word Interference), subjective measures of executive function (Behavior Rating Inventory of Executive Function-Adult, BRIEF-A) and emotion regulation (Difficulties in Emotion Regulation Scale, DERS; Symptom Assessment-45 Questionnaire, SA-45; Buss-Perry Aggression Questionnaire, BPAQ) were completed.

Results: Collegiate athletes (Mage = 19 yrs, SD = 1.29) with self-reported history of concussion/mTBI (n = 26) and without concussion/mTBI (n = 27) played a variety of sports including soccer, wrestling, lacrosse, football, and basketball. The majority of reported TBIs were mild (80%) or subconcussive (20%) (e.g., Silverberg et al., 2023). More than half (58%, n = 15) of the athletes reported sustaining multiple concussions. Athletes with self-reported mTBI were significantly less accurate and efficient on measures of executive function relative to their peers without mTBI, especially with increasing task demands and complexity (e.g., DKEFS TMT LN-Sequencing, mTBI: M = 66.12 secs, SD = 27.31; no mTBI M = 51.85, SD = 15.35, p < .05). Athletes with mTBI demonstrated difficulties with self-monitoring in that they made significantly more repetition and set-loss errors, and had poorer accuracy than those without mTBI (D-KEFS Letter Word Fluency, p < .01; D-KEFS Category Switching Fluency, p < .01, .05). Self-reported executive function (i.e., BRIEF-A) did not differ significantly between groups. Emotion dysregulation was endorsed less than hypothesized (DERS; SA-45), however, significantly more physical aggression (BPAQ) was acknowledged by athletes with mTBI (M = 18.27, SD = 6.82) relative to no-mTBI (M = 15.48, SD = 4.49, p < .05).

Conclusions: Consistent with the literature, this study highlights post-mTBI/concussion sequelae for high-level athletes particularly difficulties with executive functioning and aspects of emotion regulation relative to their peers. Complex bidirectional prefrontal and subcortical circuitry subserve executive function and emotion regulation (Martin & Ochsner, 2016). Pre – and – postinjury factors including cognitive reserve, recovery trajectory and treatment should be explored. Postinjury sequelae, symptom monitoring, and therapeutic intervention is warranted for collegiate athletes.

Over 40% of individuals who experience moderate-severe traumatic brain injury (msTBI) continue to experience life-long challenges and adjustment to their psychological, cognitive, social, and physical well-being[1]. TBI is unique in that accompanying disability may not always be overtly visible, adding to the misconceptions of injury[2]. Physical indicators of injury following TBI can include scars or differences in balance or gait, though numerous other indicators of injury are far less obvious, which include changes in cognition, mood, and motivation[3,4]. Most research focuses on the psychosocial impact of TBI when the injury is “invisible”[5-7]. Fewer research exists which directly compares the impact of visible indicators of injury on psychosocial functioning and growth.

We analyzed data from a mixed-methods pilot study exploring change in health, identity, and well-being among 40 individuals with msTBI, of which n = 24 endorsed visible indicators of injury and n = 11 endorsed identified as someone with a disability. Outcomes included functional recovery (GOSE9), self-rated recovery, community enfranchisement (CPI), quality of life (QOLIBRI), social support (ISEL-12), mental health symptoms (GAD-2, PHQ-2, PC-PTSD), event centrality (CES-7), coping styles (Brief COPE), and posttraumatic growth (PTGI).

When assessed independently, GOSE9, self-rated recovery, CPI-participation importance scores were lower for those with visible indicators and disability identity compared to those without. CES-7 scores were marginally higher for both groups (ps = .055). Those with visible indicators reported significantly lower ISEL-12, PTGI-Relating to Others subscale and PHQ-2 scores, whereas those with disability identity reported lower GAD-2 scores only. When identity variables were combined and evaluated using ANOVA, results revealed that individuals with visible injury and disability identity (n = 10) reported significantly lower GOSE9 and self-rated recovery compared to those without visible injury and without disability identity (n = 14). Further, those with visible injury and disability identity reported lower ISEL-12-Belonging and PTGI-Relating to Others scores compared to those without visible injury, regardless of disability identity (n = 16). Qualitatively-derived themes regarding change and growth following injury were summarized for each identity group to highlight contextual factors around a) functional recovery and b) social connection and relationships.

TBI is often considered an “invisible injury” relative to other lifelong conditions[8]. However, the public stigma and its associated negative impact on survivors’ psychosocial functioning and growth are just as profound[9]. Results provide initial evidence of the importance of identity variables in the functional and psychosocial well-being of individuals following msTBI. Understanding how visible indicators (or lack thereof) of msTBI may drive perceived stigma among individuals and their social network would be paramount to promoting social well-being, connection[10], and positive disability identity development[11].

Background: Brain injury among survivors of gender-based violence (GBV) is a critical issue, with 75-92% of women likely experiencing traumatic brain injury (TBI) from facial, head, and neck injuries. Research in Canada reveals a significant lack of awareness and research regarding TBI among both GBV service providers and survivors, which limits supports available to those affected. The intersection of GBV and TBI is important, as each is associated with cognitive, mental, emotional, and physical health challenges as well as elevated rates of unemployment, poverty, and houselessness. These issues lead to considerable economic impacts, including lost income, and higher costs for social and health-related services, thereby highlighting the need for GBV-TBI to be widely recognized and uniquely addressed.

Aim: This project addressed the gaps in research, support, and education for GBV-TBI survivors by piloting and evaluating a trauma-informed, multi-sectoral program. Utilizing the RE-AIM framework, the study assessed the effectiveness of a live-adapted program across diverse settings and populations in Canada. This program is survivor-led and developed with the support of WomenatthecentrE's Survivor Expert Collective (WE SEC).

METHODS: Twenty-five survivors from across Canada participated in a 20-week pilot program. An intake worker assisted survivors in identifying personal goals and necessary accommodations before joining the program. Participants completed a pre-survey to gather demographic data, health information, and details on their respective GBV-TBI causes and symptoms, along with their knowledge of any associated coping strategies.

Survivors were matched with peer navigators, who provided one-on-one sessions of peer support, advocacy, system navigation, and referral services. In addition, participants could engage in virtual peer support groups, workshops, and group activities, such as music therapy, yoga, naturopathy, speech language pathology, and psychotherapy. Participants completed four interim surveys over the 20 weeks to ascertain any gained knowledge and experiences and to provide, feedback allowing for real-time adaptations of the program. Upon completion of the program, a post-survey and a follow-up focus group were administered to evaluate the effectiveness and impact of the program. Quantitative data was analyzed using SPSS, while qualitative data and thematic coding was processed through MAXQDA.

Results: Participants benefited from project involvement through direct support for GBV/TBI related challenges. Some of these benefits included increased education around GBV and TBI care practices, pain management, and effective communications. Urgent needs around food access, housing, and financial security were also addressed. Participants stated feeling increased confidence and self-esteem, being better equipped to manage stress and GBV/TBI related symptoms with an overall increase in sense of community and agency.

Conclusion: The findings from this study will advance understanding of how to support survivors of GBV-TBI more effectively, and our knowledge mobilization framework will ensure adaptable sustainability efforts across the nation.

Introduction: Traumatic brain injury (TBI) is the leading cause of trauma-related death and disability in children. Evidence suggests that there are gaps in the quality of care provided to almost half of all pediatric trauma patients in Canada. Lack of adherence to clinical practice guidelines (CPG) recommendations may be due to lack of knowledge about their existence, their heterogeneity or the concern about their quality. Currently, no data addressing the adherence to CPG recommendations for moderate or severe pediatric TBI in Canada or in variations in practice are available. The objectives of this study are to estimate the adherence to recommendations for children under 16 years old admitted to a Canadian hospital center with moderate to severe TBI and to evaluate inter-hospital and interprovincial variations in adherence to these recommendations.

Methods: We conducted a multicenter retrospective cohort study using the hospitalization data for children under 16 years old with the diagnosis of moderate to severe TBI in all Canadian provinces except Quebec provided by the Canadian Institute for Health Information between January 1, 2016 and March 31, 2020. To measure adherence to recommendations for moderate to severe pediatric TBI, we iteratively created coding algorithms based on the available literature and clinical experts views. We carried out multilevel logistic regression models adjusting for potentially confounding variables such as age, sex, severity and concomitant injuries. Interclass correlation coefficients obtained from multilevel random intercept logistic regression models were used to quantify inter-hospital variations. Odds ratios using Ontario as the reference (most populous province) were used to quantify inter-provincial variations.

Results: We developed coding algorithms for the following recommendations: emergency department (ED) waiting time of less than 4 hours, admission/transfer to pediatric center, intensive care unit (ICU) admission, CT-Scan and other imaging techniques, mechanical ventilation, neurosurgical interventions (intracranial pressure monitoring, decompressive craniectomy and cerebrospinal fluid drainage) and measurement of GCS in children over 3 years old. There are significant differences between provinces regarding only two recommendations: ED waiting time of less than 4 hours and admission/transfer to pediatric center. Significant differences between hospitals within the same province for several recommendations were also registered regarding ED waiting time of less than 4 hours, ICU admission and cerebrospinal fluid drainage.

Conclusion: Our study is the first to describe adherence to CPG recommendations for the management of moderate to severe pediatric TBI in Canada. There are interhospital and interprovincial differences in the application of several recommendations.

For persons with disorder of consciousness (DoC) after traumatic brain injury (TBI), the therapeutic potential of repetitive Transcranial Magnetic Stimulation (rTMS) was introduced in 2006. Emerging evidence, since then, indicates that some patients benefit from rTMS. Concerns remain, however, that rTMS will exacerbate an already elevated risk of seizures. To advance understanding of rTMS-related seizure risk for persons with DoC after TBI, results from a meta-analysis will be reported. To encourage collaborations, results will be reported within the context of the data needed for FDA approved clinical use in the United States.

The meta-analysis was based on a sample of people remaining in a state of DoC for 6.5 months to 15 years after TBI (n = 20) and who received either active rTMS (n = 17) or placebo rTMS (n = 3). The sample was derived from three rTMS clinical trials, two within-subject and one was a double blind randomized placebo-controlled trial. Each trial used the same 10Hz rTMS protocol to provide 30 rTMS sessions with rTMS delivered to the dorsolateral prefrontal cortex that is aligned with current safety guidelines.

During each trial’s rTMS treatment phase, seizure occurrences were compared between active and placebo groups using logistic regression. After stratifying active group participants by presence/absence of seizure occurrences, sub-groups were compared using contingency chi-square tests of independence and relative risk (RR) ratios.

Two participants experienced seizures (1-active, 1-placebo). Post seizure, both participants returned to baseline neurobehavioral function. Both participants received antiepileptics throughout all remaining rTMS treatment sessions, that were completed without further seizures. Similar to baseline seizure risk, the rTMS-related seizure incidence rate is 59 per 1,000 persons. Logistic regression revealed no difference in seizure occurrence by treatment condition (active vs. placebo) or when examined with seizure risk factors (p > 0.1). Presence of ventriculoperitoneal shunt elevated seizure risk (RR: 2.0).

In conclusion, the findings based on this meta-analysis provide the foundation toward achieving the long-term goal of obtaining FDA approval for clinical use of rTMS in persons with DoC after TBI. Specifically, these phase I safety findings demonstrate absence of harm for a small group of participants who met medically conservative study eligibility criteria. Collectively, findings indicate a low likelihood that the specified rTMS protocol exacerbates baseline seizure rates in persons with DoC after TBI. In the presence of VP shunts, however, rTMS likely elevates baseline seizure risk and mitigation of this increased risk with pharmacological seizure prophylaxis should be considered. The findings also support broadening study eligibility criteria to address next step(s) in the FDA approval process, which involves demonstrating safety and efficacy in a larger and more diverse cohort based on a clinical trial powered to detect at least a moderate therapeutic effect.

Background: Individuals with acquired brain injury (ABI) often experience loss of vocation, recreation, and social support due to chronic physical, cognitive, and social-emotional impairments. These impairments frequently persist, creating a need for community-based exercise and social connection programs.

Objective: This study introduced a community-based adaptive exercise program and evaluated the perceived barriers and facilitators to engagement, as experienced by individuals with ABI.

Methods: We conducted a descriptive qualitative study with 18 participants. A semi-structured interview guide was utilized during focus groups and interviews with participants who completed an 8-week pilot randomized controlled trial comparing two adaptive exercise programs. Interviews were audio-recorded, transcribed, and de-identified. We deductively coded the transcripts to the 14 domains in the Theoretical Domains Framework (TDF; e.g., knowledge, skill, environment).

Results: The primary theme generated from the data was: Survivors of ABI value an accessible and supportive environment in community-based, adaptive exercise programs. Eleven TDF domains were identified as facilitators and four as barriers, with three domains repeatedly emphasized by participants. The 'skill' and 'emotion' domains were described as primary facilitators. Interestingly, the 'environment' domain was identified as both a facilitator and a barrier. The 'skill' of the adaptive exercise program instructors made participants feel safe because they could modify the exercises as the program progressed. A participant stated, “it was nice to be able to feel like you were participating and completing that task that was asked for but at the level you're safe and comfortable”. Safety related to 'emotion' was fostered by being a part of a group where every participant had an ABI. One participant stated, “I’m so self-conscious, you know, to just be in my body, listen to the instructions, and just do. Not look around at what everyone else is doing. Are they looking at me? You know…from the beginning, I was able to do that…I felt it from the participants, the energy from participants really makes a difference. Everyone in there is brain injured. And we're all in there to get some help with that”. Regarding 'environment', facilitators included the setting, timing and structure of the program. As a barrier, participants reported receiving unclear directions for navigating pre-intervention data collection sessions, especially related to parking and building access, increased stress and reduced their desire to attend the adaptive exercise programs. Participants recommended study personnel provide multimodal, detailed communication regarding access and expectations during the study to assist their ability to navigate a new environment.

Conclusion: Our findings suggest that survivors of ABI are more likely to engage in a community-based adaptive exercise program when there is frequent communication with clear directions to support access, modifications are normalized with physical support available, and the experience is shared with other individuals with ABI.

After a severe acquired brain injury (ABI), patients may present disorders of consciousness (DOC), from unresponsive wakefulness syndrome/vegetative state (UWS/VS) to minimally conscious state (MCS). These patients show severe oropharyngeal dysphagia. The assessment and clinical treatment of swallowing dysfunctions are crucial due to functional consequences and related comorbidities.
Recent studies suggested that an effective oral phase could be determinant in contribuiting to identify swallowing as a conscious behaviour.
This study aims to examine knowledge on oropharyngeal dysphagia in subjects with DOC.

Objective:
- Investigate correlations between swallowing severity and DOC.
- Analyze swallowing features and their potential role as a diagnostic and prognostic criterion for consciousness disorders. This includes tracing the evolution of both behavioral and swallowing disorders through longitudinal evaluations and identifying prognostic factors that could suggest different recovery profiles for DOC.

Methods: This is a prospective observational study involving people with DOC. All patients accessing the Acquired Brain Injury Unit at the University Hospital of Ferrara and meeting the inclusion criteria will be enrolled. Inclusion criteria: males and females over 18 years, diagnosed with prolonged consciousness disorder (more than 28 days after brain injury) classified as MCS or UWS/VS according to Giacino, resulting from severe brain injury of different aetiology (traumatic, vascular, anoxic, neoplastic and infective) within 3 months from the event.
Clinical and demographic information will be collected at admission (age, sex, time since the event, etiology, presence and characteristics of tracheostomy, prescribed drugs). All patients will assessed through the Coma Recovery Scale-Revised (CRS-R) and the Swallowing Assessment in Disorders of Consciousness (SWADOC). These assessments will take place at rehabilitation admission (T0), after 2 weeks (T1), 4 weeks (T2), 8 weeks (T3), 12 weeks (T4), and 6 months (T5). Instrumental evaluation will include: EEG recording (20-minute resting-state) at T0, T2, and T4; when feasible (presence of therapeutic feeding), patients will be assessed also with Fiberoptic Endoscopic Evaluation of Swallowing. Rehabilitation treatment of dysphagia will be daily recorded in a clinical diary, compiled by a therapist, including information on dosage, frequency, and type of stimulations.
Data will be analyzed in subgroups based on etiology, depending on sample size achieved.

Expected Results: The type of oropharyngeal dysphagia found in DOC, the evolution of consciousness disorder, swallowing behavior, and potential clinical and temporal correlations.

Limitations: The expected limited sample size may alter the generalizability of the study results. Moreover, the wide inclusion time-frame (within 3 months) could induce to clinical differences in recovery timing; indeed, these data will be managed in data analysis.

Conclusion: Swallowing assessment and treatment are crucial elements in rehabilitation of patients with DOC after severe ABI. This study aims to deepen knowledges about oropharyngeal dysphagia in DOC, analyzing its role on functional recovery in this population.

Introduction: Severe acquired brain injury (ABI) result in multiple and complex impairments, with disabling outcomes that represent a significant healthcare and social concern. These patients experience cognitive and behavioral disorders, impacting family, social, and work. Additionally, psychiatric issues are often reported in these patients.
The aim of this study is to investigate the evolution of outcomes in patients with severe ABI during rehabilitation, focusing on cognitive-behavioral outcomes and potential psychiatric issues, global outcome, and discharge destination. This investigation is preliminary to a study that will examine outcomes 2-3 years post-discharge, focusing on quality of life, the impact of cognitive-behavioral outcomes on caregivers, and the patient’s participation in daily activities.

Methods: We retrospectively analyzed a database of patients with severe ABI of different etiologies (vascular, traumatic, anoxic, neoplastic, infectious) who were admitted to the Severe Brain Injury Unit at the University Hospital of Ferrara between January 1, 2021, and December 31, 2022, for comprehensive rehabilitation. All patients with an initial Level of Cognitive Functioning (LCF) score between 2 and 7 were analyzed. Patients who did not show emergence from a disorder of consciousness based on the Coma Recovery Scale-Revised were subsequently excluded. The patients with a discharge LCF score between 4 and 7 were enrolled. LCF and global outcome scores (using the Glasgow Outcome Scale Extended, GOSE) were assessed at admission and discharge, as well as the discharge destination. We analyzed how many patients underwent psychiatric evaluation and which were the main reasons for such consultations.

Results : A total of 142 patients with severe ABI of various etiologies (vascular 69, traumatic 54, anoxic 7, neoplastic 4, infectious 8) were enrolled. The average age was 52 years. The mean LCF score at admission was 4.8, and at discharge, it was 6.7. The mean GOSE score at admission was 3.4, and at discharge, it was 5. Out of the total, 116 patients were discharged home with an average LCF score of 6.3 and a GOSE score of 5.28. 4 patients continued intensive rehabilitation closer to their residence, while 22 were admitted to long-term care facilities. Psychiatric consultations were requested for 37 patients, (psychomotor agitation, aggression, mood depression, sleep-wake disturbances, emotional discontrol, and psychiatric treatment adjustments). 17 of these patients had a previous psychiatric history, particularly substance abuse, anxiety-depressive syndrome, and bipolar disorder.

Conclusions : The study observed an overall improvement in cognitive-behavioral function and GOSE at discharge from rehabilitation. Patients admitted to residential facilities had more severe cognitive impairment compared to those discharged home. 26% of patients showed psychiatric issues requiring specialized evaluation. Further research is needed to examine long-term cognitive outcomes, the possible presence of psychiatric disorders, and their functional impact on quality of life, patient participation, and the burden on caregivers.

Introduction: Intimate partner violence (IPV) often involves several forms of abuse, including physical violence, which can lead to traumatic brain injury (TBI). For women victims of IPV, TBI can significantly impair their cognitive, emotional, and physical capacities, directly affecting their ability to assume parental responsibilities. Protecting women and their children against violence from their partners requires a multitude of services, including child protection authorities and women’s shelters. However, navigating legal systems, particularly those related to child protection, can be daunting for women, particularly when they must also manage the consequences of TBI and the reality of living within a women’s shelter. Though occupational therapy (OT) services have the potential of providing crucial services to these women, particularly in addressing their parental roles, few OT services specialized in TBI rehabilitation are provided within the context of women’s shelters in Montreal Canada.

Objectives: This study aims to explore the potential role of OT in evaluating and documenting the parenting capacities of women with possible TBI, living within women’s shelters, while also considering the potential legal implications of these evaluations in judicial processes.

Methods: This study used a qualitative, descriptive, and exploratory design. Three focus groups were conducted to gather data: one involving occupational therapists (n= 6) with expertise in IPV, TBI, and child protection cases, and the other two with both occupational therapists and legal experts specializing in family law (n=1), criminal justice (n=1), and forensic evaluations (n=1). Staff from local shelters for women (n=2) also participated in all three focus groups. Data were analyzed using thematic analysis, focusing on the challenges and strategies related to supporting the parental roles of women victims of IPV with possible TBI.

Results: Preliminary findings revealed key themes and subthemes that highlight the clinical and legal complexities of these cases. These include : 1) the potential for harm due to incomplete or misinterpreted documentation, influenced by professional mandates and inconsistencies in the interpretation of reports among different professionals; 2) the multifaceted effects of IPV and TBI, which complicate accurate assessments—compounded by factors such as insufficient trauma-informed care education and societal biases affecting professional judgments; 3) strategies to address these challenges, emphasizing the need for trauma-informed approaches that integrate women’s coping mechanisms and strengths.

Conclusion: In conclusion, there is a need for an increased offer of TBI-informed OT services in women’s shelters and improved documentation of these services, particularly in legal contexts involving child protection. Particular attention needs to be paid to what information is (or is not) included in a report, and how it is documented. This study underscores the importance of multidisciplinary collaboration and continued education in trauma-informed care to reduce harm and enhance the support provided to women victims of IPV and TBI.

Introduction: Intimate Partner Violence (IPV) is a global public health and public safety issue. The World Health Organization estimates that approximately one in three women worldwide experiences IPV. Among victims of physical IPV, it is estimated that up to 75% also suffer from traumatic brain injury (TBI) due to blows to the head. Despite the high prevalence of both IPV and TBI, their intersection is often overlooked, leading to a lack of screening for possible TBI within IPV services and possible IPV within TBI services, siloed service provision, and inadequate care for women victims of TBI secondary to IPV. This study aimed to map the first points of contact for women survivors of IPV and potential TBI across various service providers in Montreal, Quebec, Canada, and to assess the level of collaboration between TBI and IPV services.

Methods: This study is the first phase of a multi-step, community-based participatory research project. In this phase, a law student and an occupational therapy student conducted field observations and guided individual interviews with professionals from key service providers, including the Montreal police force (SPVM), Juripop (accessible legal services), Crime Victims Assistance Center, Côté Cour (social work services for IPV cases in the criminal justice system), Alliance MH2 (second-stage shelters for women and children victims of IPV), and healthcare professionals specialized in TBI. The findings were synthesized and analyzed according to Lévesque's (2013) framework of accessibility to care, with a focus on service communication, collaboration, and appropriateness.

Results: Preliminary findings indicate several entry points to IPV services in Montreal. However, there appears to be variability in the extent to which these services are accessible to this population. Moreover, existing entry points do not always provide or lead to the person receiving all necessary services, nor are they consistently referred to other essential resources. Results also show the limited interconnection between service sectors with initial points of contact within the justice system not screening for TBI nor referring to TBI services. Likewise, TBI-focused services lack specific expertise in addressing the needs of women victims of IPV. Further, we found a relative absence of health/rehabilitation and community-based services targeting the needs of this population with double vulnerability.

Conclusion: Considering the high prevalence of IPV-related TBI, it is essential to foster collaboration across all service sectors to provide more integrated, accessible, and patient-centered care for this vulnerable population. Enhanced cross-sector collaboration, including the health-rehabilitation system, and targeted training on the intersection of IPV and TBI is crucial to ensuring comprehensive support for survivors and establishing an integrated and adapted ecosystem of care for survivors.

Background: Severe acquired brain injury could lead to disorders of consciousness, a condition often characterized by reduced alpha brain activity among other things. Previous studies have suggested that transcranial alternate current stimulation (tACS) could be a promising technique to increase alpha-band spectral power in humans. However, its clinical application, particularly in intensive care units, poses significant challenges. These include the need for precise brain access, specialized training, and contraindications such as craniectomy or recent seizures. To overcome these limitations, we explored alternative, simpler techniques to improve the alpha spectral power. This study aims to determine which peripheral stimulation technique is most efficient in synchronizing alpha brain activity in healthy subjects.

Methods: A total of 44 healthy participants (i.e.; no prior history of neurological or psychological conditions, upper limb fracture of luxation and hearing deficit, not taking medication with brain effects) were subdivided into two groups of 22 and took part in a crossover study. Group 1 was administered two median nerve stimulation protocols (10.5 Hz and 40 Hz stimulation frequency) at the right wrist while Group 2 was administered two distinct auditory protocols (binaural beat 400-410Hz sounds and auditory clicks presented at a frequency of 10 Hz). The presentation order of the conditions was counterbalanced between subjects. These protocols involved 13 stimulation cycles of 1 min followed by a 30-second rest period during continuous EEG recording. Each protocol was preceded and followed by a resting EEG (3 min eyes open and 3 min eyes closed) (Biosemi, Amsterdam, Netherlands). Tolerability and side effects were recorded.

Results: Group 1 included 22 participants: 30.7 ± 7.1 years old, ratio M:F 11:11, and 3 left-handed. Group 2 included 22 participants: 30.7 ± 7.6 years old, ratio M:F 11:11, and 5 left handed. Tolerability: Only mild side effects were observed and included scratching and tingling at the wrist for the median nerve stimulation and mild drowsiness in participants during auditory stimulation. Although still underway, preliminary analyses suggest that 10 Hz median nerve and auditory click stimulation conditions generated a significantly greater entrainment effect on endogenous alpha activity than 40-Hz median nerve stimulation and binaural 400-410 Hz beat. Further analyses will integrate previous data from tACS stimulation in controls to directly compare brain alpha activity modulation from peripheral as opposed to central stimulation.

For children who sustain traumatic brain injury (TBI), there are no evidence based guidelines to help clinicians make return to play (RTP) decisions if the injury was anything more severe than a mild TBI. Accordingly, we sought to understand the practice patterns of experts in pediatric traumatic brain injury (TBI) in relation to how they assess severity of TBI and guide RTP decisions with their patients who sustain complicated mild, moderate, or severe TBI.

We conducted a cross-sectional web-based survey of experts (defined by attesting to their clinical management of children with TBI including RTP decisions and demonstrating a history of publication in the area of pediatric TBI including mild TBI). 55 candidates were invited, and 37 responded (67% response rate). 30 met eligibility criteria and answered our complete survey, representing the medical specialties of physical medicine and rehabilitation, neurology, neurosurgery, sports medicine, and neuropsychology.

Our outcome measures included ratings of agreement as to the relative importance of a variety of factors used to assess initial severity of injury as well as to measure recovery. RTP timelines were measured for different scenarios assuming the child had completely recovered (adjusted by level of risk of activity returned to and the severity of initial injury sustained). Finally, ratings of agreement with various factors which could influence their RTP decision making as well as a free text option.

Recommendations on RTP timing varied significantly based on risk of activity returned to for all levels of TBI severity (p < 0.05). There was large variability of RTP timeline for any given level of injury severity. There was no significant association between medical specialty and RTP recommendations. Factors necessitating a longer duration before allowing RTP and which received 80% or greater agreement (noted agree or strongly agree) included: degree of recovery which does not reach pre-injury baseline (93%), higher degree of contact/risk in the sport of interest (90%), the requirement of surgical intervention (82%), and returning to a competitive as opposed to a recreational playing environment (80%).

In conclusion, these results can inform clinicians who care for children with TBI in their own RTP decision making. The description of these RTP trends, in combination with the variability seen in both severity determination and recovery assessment, highlight the importance of further study of outcomes related to RTP and the eventual development of standardized guidelines for this patient population.

Participation is frequently viewed as a key determinant of health. The World Health Organization's International Classification of Functioning, Disability and Health calls on clinicians to provide care that impacts their participation in valued life situations (WHO 2007). However, researchers are beginning to discuss the concept of participation as a “bidirectional construct” that “can be both an entry point (‘process’) and an outcome ('endpoint') of health and education services” (Imms 2017).

Although there is growing evidence supporting participation-focused assessment and intervention (Anaby 2021), clinical care continues to consist primarily of assessments and interventions with focus on body functions and impairments. This is particularly true for the Disorders of Consciousness (DoC) population. While serial assessment and protocols are a crucial component of acute management of DoC in order to understand current level of function and restore premorbid body functions, this often hinders the ability to engage patients in salient and participation-focused interventions. Fisher discusses the ethical challenges and importance of focusing on patients' values and notes that, although it will add complexity to patient management, “it is crucial to providing honest and ethical care” (Fisher 2017). This oral abstract integrates the concepts participation as a therapeutic ‘process’ and providing optimal ethical care to the pediatric DoC population, while identifying current barriers and advantages to implementation within this unique population.

While shifting goals of care to participation-focused interventions is optimal, it can be a challenging transition for families and clinicians as this “requires shift in perspective/values: from promoting doing things normally and correctly, nicely, or independently” (Anaby 2021). This can be especially challenging for the DOC population as patients have sustained significant functional changes that drastically impact the way preferred activities are executed compared to baseline. A TBI Models System Study found that patients who enter rehab without consistent command-following (even if having emerged prior to discharge) experience profoundly impaired levels of participation years later, even when compared to normative participation levels of individuals currently treated in inpatient rehabilitation (Malone 2019).

While many challenges exist with implementing participation-focused interventions, researchers have found that interventions focusing context and “real life” situations have demonstrated the most favorable outcomes for patients experiencing traumatic brain injury (Sveen 2022). Current research supports the use of salient stimuli and pre-injury hobbies are most effective for the pediatric DoC population (Irzan 2022). This focus on participation, particularly when including caregivers, may also ease the transition and quality of life following rehabilitation for families of patients experiencing DoC. In this oral abstract, we draw on current growing research in participation-focused practice and clinical experience with the pediatric DoC population to discuss barriers and in implementing a plan of care in which participation is the primary focus and outcomes indicator for intervention.

Background: Concussion elicits of variety of molecular alterations that reflect ongoing injury and perturbations. Historically, these alterations have been characterized using venous blood collected through phlebotomy. However, there are significant challenges to this including its perceived invasiveness, and participants apprehension and fear in addition to logistical challenges associated with its collection, processing and storage. As such, microsampling technologies have emerged as a potential tool in place of standard venipuncture for blood collection in research studies, yet still need to be developed and validated, particularly in the context of brain injury.

Purpose: The purpose of this study to examine how two, novel microsampling technologies perform compared to traditional venipuncture.

Methods: This cross-sectional study recruited healthy (i.e., uninjured within the last two weeks) participants ages 18-30 years old with no history of adverse reactions to blood. Demographics and blood screening forms were collected. Peripheral venous blood was drawn using standard phlebotomy techniques and capillary whole blood was collected from two additional devices: 1) a finger prick, and 2) upper arm prick. Inflammatory cytokines and chemokines will be quantitated using a high-multiplex immunoassay platform.

Results: Twenty-eight healthy participants were enrolled in the study (n=14 males, n=14 females). Median and interquartile range of height and weight of participants was 174 (165.75-182.25) cm and 78 (64.5-87.5) kg. Four (15%) participants had a diagnosed learning disability, five (19%) participants had a diagnosed psychiatric disorder, and ten (38%) participants had a history of concussion. Twenty-six participants completed all three blood samples, 2 (8%) experienced adverse reactions one of the blood collection techniques. Most participants preferred the upper arm device device (n=19, 79%) while the remaining (n=5, 21%) preferred the finger prick blood collection device. Concentrations of twenty-one inflammatory cytokines and chemokines will be reported and compared for this study.

Conclusion: Preliminary findings suggest that microsampling technologies can be implemented in a healthy population with minimal adverse outcomes. Among healthy individuals, the upper arm device is the preferred blood collection method for participants. The quantitation of inflammatory biomarkers will provide information regarding the performance of microsampling technologies and how they compare to venipuncture for future application in brain injury.

Introduction: Crucial clinical decisions in the acute-to-subacute stages of severe traumatic brain injury (sTBI) are mostly limited to neurological exams and behavioral assessments. While EEG-derived indices of consciousness are promising, their effectiveness in tracking single-subject recovery over time remains to be assessed. This study characterizes the longitudinal progression of consciousness recovery following sTBI, validating EEG spectral power and aperiodic exponent markers, considering sex, etiology and age.

Methods: Four medically stable, non-sedated sTBI patients were selected from an ICU study (7-26 days post-injury). Participants were selected based on etiology (sTBI), age (M = 30 years, SD = 1.41 years), lesion severity (diffuse axonal injury), and behavioral responsiveness levels according to the (Coma Recovery Scale-Revised, CRS-R). Five-minute resting-state EEG and CRS-R assessments were conducted daily for six days, with an additional recording a week after.

Results: Significant variations in power spectral distribution and the aperiodic component were observed over time, even within similar diagnostic categories. The EEG aperiodic component exhibited a similar improvement trajectory to behavioral responsiveness, with a progressive flattening of the EEG slope in two individuals. In contrast, the other two individuals showed aperiodic component fluctuations over time while remaining stable in a CRS-R category. While alpha and theta spatial power distribution did not change as behavioral responsiveness improved, a shift in maximum frequency peak was observed as CRS-R scores improved.

Conclusion: This longitudinal within-subject design captured neurophysiological changes associated with patient-specific trajectories of recovery of consciousness. Spectral power and the EEG aperiodic exponent together, show promise as objective neurophysiological markers for tracking recovery. Identifying individualized EEG markers of consciousness after brain injury could expand therapeutic avenues, improve diagnosis accuracy and aid early outcome prediction.

This abstract will continue the discussion initiated regarding the definition (Jones) and application (Conklin) of participation in children with prolonged disorders of consciousness (DoC).

We have been cautioned that “focusing on evaluated well-being at the expense of experienced well-being risks underestimating overall quality of life in patients that remain capable of positive affective experiences” (Graham 2021). How do we attempt to objectively assess participation, involvement, or engagement in patients without or with limited external indications of cognitive, behavioral, or emotional outputs?

While many measures are available globally for the evaluation of participation and focus on the concept of participation for children with disabilities is growing, a gold standard participation assessment for use with pediatric patients experiencing prolonged DoC does not currently exist. Measures utilized in research to capture participation specifically for patients who have experienced DoC were designed for use with adults (e.g., PART-O; Malone 2019). Many of the current measures available for evaluating participation in children were developed for children with varying congenital disabilities (e.g., PEM-CY; Coster 2013). Existing measures may lend themselves to support increasing objectivity in rating participation but are likely to rate this patient population as having severe impairments in participation, potentially without appreciating the nuances involved.

The Disability Paradox is defined as the phenomenon through which individuals with “serious and persistent disabilities report that they experience a good or excellent quality of life” while “to most external observers these individuals seem to live an undesirable daily existence” (Albrecht 1999). Principles of neuro-ethics promote the importance of including perspectives of the individual while also noting the complexities of promoting autonomy in patients with DoC knowing that “capacities that are prerequisite to autonomy are themselves disordered” (Young 2021).

One could infer that families who perceive greater levels of functioning may be more likely to support and promote participation. Families in our follow-up clinic have reported varied levels of participation informally, but many subjectively report behaviors associated with emergence not captured in objective assessment. It is not uncommon for families of children presenting with non-responsive wakefulness syndrome to report successful use of robust eye-gaze communication systems while objective assessments indicate limited to no visual responses. Other families may report limited participation outside of school despite consistent affective responses to salient topics of conversation.

How do we balance remaining objective while also continuing to support the unique perspectives, beliefs, and needs of patients and their families? Do our current practices and protocols support or deter this from happening? How can therapists and families prioritize opportunities for engagement? This session will look to the research, clinician perspectives, and lived family experiences to guide us towards answers, and acknowledge the significant complexity in assessing participation in this population.

Background: Traumatic encephalopathy syndrome (TES) is a progressive clinical disorder associated with substantial exposure to repetitive head impacts (RHI), including symptomatic concussive and asymptomatic subconcussive injuries often incurred during routine contact and collision sport participation. A core clinical feature of TES is neurobehavioral dysregulation (NBD), a neuropsychiatric syndrome characterized by poor regulation of emotions and behavior. Given the potential anti-inflammatory properties of cannabis, recent clinical studies have begun to examine its use for the management of neuropsychiatric symptoms associated with various neurological conditions, including dementia and traumatic brain injury. Preliminary evidence suggests that cannabinoids may be associated with clinically significant improvements in several dementia-related neuropsychiatric symptoms (e.g., agitation, aggression), though findings have been equivocal. The present observational study examines the association between cannabis use and NBD among former athletes with substantial RHI exposure.

Methods: Participants were former professional (n=115) and college (n=59) American football players (ages 45-74 years) enrolled in the Diagnostics, Imaging, and Genetics Network for the Objective Study and Evaluation of Chronic Traumatic Encephalopathy (DIAGNOSE CTE) Research Project. Measures of NBD (explosivity, emotional dyscontrol, affective lability, impulsivity) were derived from an expert-informed confirmatory factor analysis with items from self-reported neuropsychiatric rating scales. Participants were categorized into four groups according to self-reported cannabis use: “never-users” (n=57), “former users” (n=80), “occasional users” (n=23), and “frequent users” (n=19). Uncontrolled, one-way ANOVAs were used to examine group differences in NBD symptoms, and post-hoc analyses were performed using Tukey’s HSD.

Results: There were significant group differences in explosivity, F(3, 173)=4.23, p=.006; impulsivity, F(3, 173)=5.04, p=.002; affective lability, F(3, 173)=5.92, p<.001; and in a total NBD score, F(3, 173)=5.86, p<.001. Post-hoc analyses revealed that frequent cannabis users had significantly higher impulsivity, affective lability, and total NBD factor scores compared to all other cannabis use groups. Additionally, frequent cannabis users exhibited higher explosivity factor scores compared to former and never users, but not occasional users.



Conclusions: The present study examined associations between self-reported cannabis use history and neuropsychiatric symptoms among former American football players. Overall, results suggest that more frequent cannabis use is associated with higher levels of NBD symptoms. It is possible that former players who report more severe symptoms attempt to use cannabis to manage these problems. However, it is also possible that more frequent cannabis use may worsen existing NBD symptoms related to RHI exposure. There may be additional factors that contribute to this relationship, such as the age of first use, which has been linked to long-term deficits in cognitive and psychosocial functioning, as well as the underlying cause(s) of the NBD symptoms.

Following severe traumatic brain injury (TBI), many patients remain non-verbal for prolonged periods of time. For those who also have severe motoric impairment, communicating even simple yes/no responses via standard modalities, such as talking or gesturing, can be impossible. In these cases, it can be difficult to determine a person's cognitive status, particularly for those who are diagnosed with a disorder of consciousness. Assessments such as the Coma Recovery Scale-Revised (CRS-R) (Giacino et al., 2004) rely on behavioral observations to determine a person's level of awareness at bedside. To test emerged from a minimally conscious state (eMCS), a patient is required to demonstrate functional object use or functional communication. For non-verbal patients with severe motoric impairments, achieving either of these two criteria can be very difficult. Early evaluation and use of Augmentative or Alternative Communication (AAC) can be integral to a patient having the right tools to demonstrate awareness during this phase of recovery. In many cases at our facility, having an accessible AAC modality has been key to a patient demonstrating eMCS on the CRS-R. Through a series of case studies, we will seek to demonstrate how early evaluation and use of AAC can provide important information about a patient's level of consciousness during assessments like the CRS-R. Additionally, we will show how AAC can be a critical component throughout a patient's rehabilitation program by providing a window into their cognitive-linguistic status that otherwise would remain inaccessible.

Prolonged disorders of consciousness (pDOC) encompass several medical syndromes characterized by severe impairment of consciousness. The most frequent causes of pDOC are traumatic brain injury, anoxia, or stroke. Given the high misdiagnosis rate, reaching up to 40% of cases, researchers are actively seeking new approaches to improve clinical diagnosis. Among the emerging methods, electroencephalography (EEG) appears as a promising alternative. In this study, we investigated the differences in EEG power spectra between unaware and aware groups of pDOC patients. The unaware group consisted of patients with Unresponsive Wakefulness Syndrome, and the aware group included patients with Minimally Conscious State Minus and Plus, and those who emerged from Minimally Conscious State. The final diagnosis was reached as the most frequent diagnosis across 5 repeated Coma Recovery Scale-Revised administrations. We modeled the EEG frequency spectra of 42 pDOC patients using the FOOOF (Fitting Oscillations & One Over F) algorithm. After that, we chose key spectral properties based on the literature and the characteristic signal properties of each pDOC group. To classify the spectra, we implemented supervised machine learning (ML) to assess its potential in facilitating the diagnostic process. Based on the aperiodic component, the central frequency of the peak with the highest amplitude, and the high-to-low frequency ratio, the ML model predicted pDOC syndromes with 77.9% accuracy (AUC = 0.79), with sensitivity equal to 76.5% and specificity of 79.5%. These findings suggest that utilizing ML for EEG power spectrum parameters enables the differentiation of different pDOC syndromes and may play a significant role in future diagnostic approaches for pDOC.

Background: There are no evidence-based standardized neurotrauma care pathways implemented at the healthcare system level that provide expert-informed guidance related to care and service provision from time of injury to life in the community, while considering the social determinants of health. Engaging diverse key partners, the Neurotrauma Care Pathways developed Ideal Care Pathways for traumatic brain injuries (TBI; mild/concussion and moderate to severe). The TBI Care Pathways address known gaps in care related to, for example, unclear expectations during patient journeys, non-standardized concussion identification, and the much-needed lifelong community supports, especially related to mental health. With the Pathways, including Quality Indicators, at hand, momentum needs to be built to address these care gaps.

Objective: to describe the implementation plan and outcomes for the TBI Care Pathways.

Methods: As part of the development of the Ideal Care Pathways and companion Quality Indicators, regional teams were identified to champion the implementation of priority aspects of the TBI Care Pathway. The implementation strategy consisted of several components: catalyst grants for the regional teams with implementation support; collaboration with regional Acquired Brain Injury System Navigators; engagement of healthcare funders in Quality Indicator collection; audit and feedback through Report Cards; and creation of policy briefs. Each implementation project was co-designed with persons with lived experience (PWLE) and their families and grounded in the principles of implementation science. Quality Indicator collection was facilitated.

Results: Implementation priorities were established and included two common priorities across the province: education for PWLE and their families, and care coordination and navigation. Six formal pilot implementation projects have been completed and the resulting care maps, implementation manuals, sustainability plans and project-specific evaluation data are publicly available online. Implementation projects addressed navigation, PTSD, primary care checklists, Well Being and key acute care clinical practices. Audit and feedback reports have been produced that characterize publicly funded and insurance funded care. Additional priorities have been added to improve Care Pathways to better support older persons after TBI and those with mental health challenges. Current projects involve the scale and spread of original projects, implementation of Quality Indicators in both publicly funded and insurance funded care, building awareness among funders of the inefficiencies and ineffectiveness of current TBI Care and piloting of new models of integrated multidisciplinary primary care. Implementation and knowledge mobilization results relevant to clinicians, healthcare planners and funders will be presented.

Conclusions: These evidence-based Ideal Care Pathways represent a road map for quality improvement with a strong emphasis on community care, transitions and proactive chronic care management. This work represents the initial steps of the journey towards ensuring that all persons living with TBI and their families receive equitable care and supports to address their chronic needs over the lifespan.

Introduction: Sustaining an acquired brain injury (ABI) can have long-term and catastrophic consequences (i.e., physical and cognitive changes). Importantly, people experience difficulty completing their activities of daily living (ADL) after injury. To facilitate improvement in ADLs, rehabilitation needs to be customized to the person’s function, goals, and environment. Virtual reality (VR) is a novel treatment approach in ABI rehabilitation that aims to improve physical and cognitive deficits using a tailored and individualized approach. Specifically, the Saebo-VR is a platform with ADL tasks (i.e., grocery shopping, meal preparation) designed for people with ABI to improve physical, cognitive, and ADL function. However, the feasibility of using a VR device such as the Saebo-VR in clinical settings is not known.

Objective: To explore the feasibility of using VR to practice ADLs to improve physical (i.e., upper limb), cognitive, and ADL function after ABI.

Methods: A mixed methods pre- and post-intervention study was conducted using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Participants included people with ABI (i.e., stroke and moderate-to-severe traumatic brain injury) within 1-year of injury receiving inpatient or outpatient therapy at a rehabilitation centre. Participants with ABI participated in 12 30-minute VR sessions over 3-weeks using the Saebo-VR to practice ADLs. Occupational therapist (OT) participants were recruited to facilitate sessions. The sessions were facilitated by OTs or trained research staff. Outcome measures were collected at baseline, post-intervention, and at 3-months post-intervention. The primary outcome measure was the Nottingham Extended ADL scale and secondary outcome measures included the Montreal Cognitive Assessment, Fugl-Myer Upper Extremity Scale, and Daily Living Self-Efficacy Scale. Facilitators video-taped 3 out of 12 sessions and completed checklists to ensure fidelity. Phenomenological semi-structured qualitative interviews were conducted with participants and OT facilitators to understand their experience during the VR sessions.

Results: 15 participants (mean age 46.8, 10 male) with ABI (2 severe TBI and 13 stroke) and 5 OTs (mean age 37.8, 5 female) were recruited. All feasibility indicators were achieved. For reach, 23.1% participants with ABI and 56% of OT participants were included in our study. For effectiveness, paired t-tests indicated improvements from baseline to post-intervention. For adoption, participants with ABI outlined barriers with VR included unfamiliarity with technology; facilitators included realizing the impact of the intervention on ADL function. OT participants indicated barriers to facilitation included resource constraints; facilitators included seeing value of VR in occupational therapy. Implementation was assessed by the videos and checklists and revealed high fidelity. Maintenance was assessed post-intervention, and 60% of OT participants revealed they would use VR clinically in the future.

Conclusions: Determining the feasibility of VR in clinical practice with the ABI population may provide evidence for the use of novel approaches in therapy to enable engagement in daily activities.

Background: Brain injury and other acute neurological conditions associated with immobility carry risk of venous thromboembolism (VTE). However, the most appropriate duration of treatment where reduced mobility persists remains undefined. Evidence that heparin may have a neuroprotective effect following haemorrhagic brain injury also adds to the treatment decision dilemma. Anecdotal evidence suggests that informal policies for VTE prevention have evolved in rehabilitation units in the absence of any nationally or internationally recognised guideline. This identifies a need to clarify the evidence base for VTE prevention. AIMS The aim is to review evidence in relation to VTE risk and its management in the neurorehabilitation setting.

Methods: Systematic searches were carried out using the Medline database. Search strategies combined variations on the terms “brain injury” or “stroke” or “neurorehabilitation” with terms that described “VTE/venous thromboembolism” and with the term “prophylaxis”. Relevant articles were selected for inclusion in a narrative review.

Results: The majority of articles focused on epidemiology and risk factors including screening for asymptomatic VTE. Three articles reported prevalence of subclinical DVT at time of neurorehabilitation admission (through duplex ultrasound screening) with rates varying between 4% and 21% depending upon neurological diagnosis. There were much more limited data on the risk of new VTE developing during neurorehabilitation. One observational study used propensity score adjustment to examine the efficacy of pharmacological VTE prophylaxis in traumatic brain injury rehabilitation. This did not show a clear benefit in favour of treatment and rates of VTE were low (1.6% in those with treatment and 1.8% in those without). There are more data relating to VTE prevention after stroke, with studies reporting effectiveness of both mechanical (Intermittent pneumatic compression devices) and pharmacological prophylactic strategies. These give varying estimates of benefit with clear risk profiles. However data to guide choice and duration of prophylaxis specifically in the neurorehabilitation setting is far more limited leaving a gap in the evidence base.

Conclusions: The evidence base for VTE prevalence and prevention is diverse. In presenting the summarised evidence we hope to trigger discussion at congress that might lead to a strategy for developing guidance.

Introduction: Acquired brain injury (ABI) is the leading cause of disability in Canada for people under 40 years old. Despite the prevalence and high needs of the ABI population, current health services often do not provide individualized and patient-oriented support to facilitate improved longer-term quality of life outcomes. Peer support is a patient-oriented intervention, directly tailored to addressing the needs of the person, which is especially important given the diversity of symptoms and outcomes experienced after ABI. This review aimed to describe the intervention and implementation strategies of peer support after ABI.

Methods: The scoping review used the Arksey and O’Malley methodology framework, with the search conducted in March 2024. Databases CINAHL, EMBASE, Medline, and PsycINFO were searched. The Reach Effectiveness Adoption Implementation Maintenance (REAIM) framework was used to describe implementation strategies. Peer-reviewed articles were included if they described at least 4 out of 5 REAIM components with both one-on-one and group support programs included. Articles were included if participants were adults and a majority of those with lived experience of brain injury. Articles were excluded if peer support was a formal program run by a healthcare professional, self-management oriented, or a control arm.

Results: Selected key results are highlighted from our analysis. The search yielded 2353 articles with 16 articles included in the review after two independent reviewers completed title and abstract screening and full text screening, excluding duplicates and those not meeting inclusion criteria. Of the 16 articles included in our review, there were nine unique peer support interventions described. Feasibility outcomes were mixed across the studies. The reach of interventions (e.g., participants recruited compared to those approached) had a large range from 20% to 93%. Effectiveness outcomes were mixed; two interventions reported significant improvements in quality of life and interpersonal support after peer support compared to controls. Qualitative studies all reported positive experiences from those who received peer support. Qualitative themes included increased knowledge and confidence after injury, and a sense of comfort from connections formed. Adoption of interventions was obtained through interventions engaging with hospitals (n = 5 interventions) and community brain injury associations (n = 6 interventions). Implementation approaches of peer training varied from one-day to one week of training or shadowing current peer support workers, while other did not have any training (n = 2 interventions). Pairing the peer support worker to the peer support receiver was based on sex and gender, similar life experiences, and similar symptoms. Maintenance of peer-support programs beyond the research study took place for six of the interventions.

Conclusions: This scoping review identified ABI peer support programming implementation strategies. The heterogeneity identified highlights the complex nature of both peer support programming and introducing interventions in the ABI populations.

Introduction: Peer support is a patient-oriented approach, integrating the expertise of people with lived experience to provide emotional and practical support with others who share a common experience. In traumatic brain injury (TBI) rehabilitation, little is known about the feasibility of integrating peer support using a community-engaged approach. Our primary objective was to evaluate the feasibility and impact of a community-based peer support program for people with moderate to severe TBI.

Methods: This mixed-methods study used a pre-post feasibility design using the Reach Effectiveness Adoption Implementation Maintenance (REAIM) framework. Participants included were adults who experienced a TBI less than 12 months ago. To understand effectiveness, we collected data on resiliency (Connor Davidson Resilience Scale), self-efficacy (General Self-Efficacy Scale), hope (Hope Hearth Index), and quality of life (EQ5D).

Results: There were 3 participants with new experience of TBI included in our study. Most measures of feasibility were achieved. Reach was achieved as 60% of participants consented to the study compared to those who were approached. Effectiveness showed minimal difference in all outcome measures from baseline to post-intervention. Adoption was maintained with 100% adherence to the intervention and the fidelity of the intervention, with > 90% of sessions aligning with session content. Implementation showed changes in the method of intervention delivery (e.g., fully virtual intervention). Maintenance was achieved as all community team members reported continuing the intervention past the research study.

Conclusions: Findings show community-engaged peer support programs are feasible for people with TBI. While there were no changes found in the quantitative measures, qualitative results suggest that meaningful connections are made through shared experiences and current life context. Future research may examine the implementation of peer support and identify outcome measures that show improvement through peer support intervention.

The intersection of intimate partner violence (IPV) and brain injury (BI) has been nearly completely overlooked in research, practice, and policy, despite the known risk associated with the two conditions. The majority of physical injuries sustained by women as a result of IPV are from battery to the head, face, and neck, including strangulation. In the IPV context, an external force, such as blunt force trauma to the head or face or violent shaking is enough to sustain neurological deficits. The lack of research on the intersection of IPV-related BI (IPV-BI) makes for limited understanding of survivor’s healthcare needs and a scarcity of services tailored to their needs. With one in three women expected to experience intimate partner violence (IPV) in their lifetime, and up to 75% of those women incurring suspected brain injuries, IPV-BI is a significant public health concern. Along with increased risk of mental health challenges, addictions, and complex health needs, IPV and BI are also associated with elevated rates of unemployment, poverty, and homelessness. These physical and social determinants of health impact women and can leave them vulnerable to ongoing violence and permanent disability. The intersection of IPV-BI is uniquely and extraordinarily complex. Each component individually presents significant challenges on multiple fronts: medically, emotionally, psychologically, economically, and socially. This complexity presents singular challenges to the development and delivery of effective, timely healthcare and social service supports. Since COVID-19, healthcare systems have experienced unprecedented strain resulting in longer wait times, fewer services available, and an inability to address the complex needs of survivors of IPV-BI, particularly in rural and remote communities. Seeking alternative approaches to addressing these gaps is of critical importance. Collaborations between knowledge producers, community-based service providers from diverse geographical areas, advocacy groups, and volunteer organizations can be one such approach. Presented here is an example of how this approach can be effective. Engaging in a community-driven collaboration with the goal of providing research expertise and knowledge support to the Canadian Royal Purple Society, the ongoing project has resulted in the development of a national campaign to address IPV-BI including public awareness events, funding and donation programs, policy impacts, and the development of blueprints for community capacity building to support and prevent IPV-BI. This ongoing project addresses a critical gap in addressing the impact of IPV-BI on survivors on both an individual and a community level. Presented here is an innovative grassroots approach to addressing the unique care needs of survivors of IPV-BI while building capacity at a local level. This talk is intended to provide insights, resources, and practical suggestions for fostering community collaborations, involve the volunteer, and work together to better support women exposed to IPV-BI.

The Coma Recovery Scale Revised (CRS-R) has been used consistently in the Craig Hospital rehabilitation center inpatient setting for over a decade. The CRS-R assessment team at Craig is a multidisciplinary team including Physical Therapists, Occupational Therapists, Speech Therapists, Recreation Therapists, Neuropsychologists, a Physician, and Clinical Research Therapists. Members of this team pair up with primary therapists to administer the CRS- R to appropriate patients in the hospital. Recently the CRS-R FAST was published by the Spaulding-Harvard Traumatic Brain Injury Model System. THE CRS-R FAST is an abbreviated version of the CRS- R validated for use in the intensive care unit as a quick and objective behavioral evaluation of level of consciousness. Our team has started to consider the best ways to integrate the CRS R FAST into our system of care and our typical testing procedures. The CRS R FAST does not provide the same amount of robust and specific information as the full CRS-R, but does provide a unique opportunity for caregivers and other staff members to objectively look for signs of consciousness and track changes in this population. So far this assessment has been used at Craig to help educate caregivers and staff members on what behavioral signs of consciousness are, provide caregivers and family members a way to look for changes in their loved one’s presentation over time, and will likely be used by primary therapists when appropriate to decrease the amount of CRS-R testing from the trained CRS-R team until a medication change or observed behavioral changes warrants more consistent CRS R testing. There are additional challenges to implementation, and because the exam has not been validated in the rehabilitation setting we are just beginning to implement the assessment into our care and are attempting to use this assessment appropriately. Our purpose is to discuss what may and may not be the best uses of the CRS-R FAST as a tool in the rehabilitation setting to help support our interventions and education provided to those caring for the Disorders of Consciousness population.

Recurrent cerebrospinal fluid (CSF) leaks in adults, especially after failed nasoseptal flap repair, pose significant challenges. This case report highlights the successful repair of a recurrent CSF leak using a minimally invasive endoscopic approach with free flap reconstruction from the anterolateral thigh (ALT), combined with neck dissection for vessel anastomosis. This technique was selected because the patient and the family refused transcranial surgery due to concerns over its risks.

Case Description: A 47-year-old patient presented with a recurrent CSF leak after a failed nasoseptal flap repair. The patient, eligible for transcranial surgery, declined the procedure. Consequently, a free flap from the anterolateral thigh was chosen due to its flexibility and appropriate surface area for covering the defect.

Surgical Technique: The endoscopic approach began with evaluation of the nasal cavity and skull base to locate the recurrent leak and assess the previous repair site. A free flap was harvested from the anterolateral thigh, and a neck dissection exposed recipient vessels, specifically branches of the external carotid artery. The flap was introduced through a transmaxillary approach and positioned over the defect. Microvascular anastomosis connected the flap’s vessels to recipient neck vessels, with intraoperative Doppler confirming blood flow and viability.

Outcomes and Conclusion: The patient’s recovery was uneventful, with no signs of leakage on follow-up imaging. This approach minimized disruption to surrounding tissues and avoided complications associated with transcranial surgery, providing a successful and less invasive alternative for recurrent CSF leak management.

Relevance for the World Congress on Brain Injury: This case presents a new endoscopic technique for treating complex skull base defects, relevant to professionals managing traumatic brain injuries. It offers a less invasive solution for patients refusing or unsuitable for traditional transcranial approaches.

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Background: Traumatic brain injury (TBI) represents a significant health concern globally, as it may result in temporary or long-lasting impairments following an external mechanical force to the brain. In the United States alone, there are approximately 1.7 million TBIs annually, leading to about 50,000 deaths. Patients who sustain a moderate or severe TBI (msTBI) usually require admission to an ICU, are unable to make their own healthcare decisions, and require the assistance of a family or friend caregiver. These caregivers are often untrained and are under tremendous stress from their loved one’s injury. Approximately one-third of these caregivers may develop long-term anxiety and depression. CG-WELL is an ongoing randomized controlled trial comparing a novel web and phone-based intervention to standard of care. The intervention includes an overview of TBI education, coping and problem-solving skills, online modules and monthly tailored follow-up phone calls to address common unmet caregiver needs that last throughout the first six months after injury. The purpose of this analysis is to compare baseline and pre-injury BSI-18 scores which reflect anxiety and depressive symptoms, and to understand factors associated with higher differences from baseline.

Methods: Participants were caregivers of patients who had sustained msTBI within the past two weeks. We obtained a BSI-18 baseline at the time of enrollment, and caregivers were queried as to how they might have responded to BSI-18 questions two weeks prior to their loved one’s injury. We evaluated the impacts of socioeconomic factors such race, caregiver education level, caregiver relationship and sex of the caregiver on BSI-18 scores.

Results: Of 78 caregivers included in this analysis, the average age was 51 years old, 76% were female,19% were male, 13% were black and 87% were non-black. Overall, caregivers had higher BSI-18 scores at baseline compared to how they may have responded two weeks prior. Mean preinjury BSI-18 scores were 4.1 and increased by 8.3 with a baseline mean of 12.7, indicating worse depressive and anxiety symptoms. Female caregivers had higher BSI-18 change score than males with an average difference of 3.83 (95% CI -10.10, 2.43). Black caregivers reported a worse change when compared to their nonblack caregiver counterparts [BSI-18 difference of 3.78 (-4.32, 11.87)]. Caregivers with education greater than high school were had higher BSI-18 scores compared to those with less education 1.23 (-4.21, 6.67).

Conclusions: Caregivers have a significant increase in BSI-18 scores following a loved one’s msTBI, reflecting the severity of depressive and anxiety symptoms. This change was worst in females, blacks, and caregivers with higher levels of education. Clinicians caring for patients with msTBI should be mindful of the substantial anxiety and depressive symptoms caregivers experience.

Background: Recovery from sport-related concussion (SRC) is multifaceted, often influenced by individual factors and the broader context of healthcare access. While studies have shown that biological sex may contribute to acute symptomatology following a concussion, findings have been mixed regarding impact on recovery duration. Improved access to care has been suggested to lessen such disparities. This study aimed to explore the role of biological sex and healthcare accessibility in recovery duration and risk for persisting symptoms following SRC in adolescent athletes.

Methods: This retrospective cohort study included athletes aged 13-18 evaluated through a pediatric academic medical center’s sports medicine program in one of two settings: a hospital-based specialty clinic or on-site at a sport focused boarding school. Inclusion criteria were an evaluation in either setting within 7 days post-SRC. The study focused on two primary independent variables: the athletes' reported biological sex, and the clinical setting where they received care. The latter was indicative of healthcare accessibility, with the boarding school providing immediate and daily access to a full spectrum of multidisciplinary sports medicine and rehabilitative services. Primary outcomes included recovery duration from injury to asymptomatic clinic encounter and persisting symptoms at 28 days post-injury. Analyses included data from athletes whose recovery duration fell within 2 standard deviations of the sample mean (N=1281).

Results: Linear regression revealed a significant association between female sex and longer recovery time (female mean days = 18.55, 95% CI =15.71-24.28; male mean days = 14.26, 95% CI = 11.55-20.12; B = -4.341, p < .001). Logistic regression echoed this finding, indicating that the odds of persisting symptoms at 28 days was 62.3% higher for females than males (Exp(B) = 0.377, p < .001). When considering clinic setting, chi-square tests demonstrated a significant association between biological sex and recovery status in the hospital-based clinic (χ² = 30.582, p < .001), with females showing a higher likelihood of persisting symptoms compared with males (21.6% and 7.7%, respectively). In contrast, no significant difference was observed in the sport focused boarding school (χ² = 0.207, p = .649). Results also indicated that athletes from the sport focused boarding school experienced lower rates of persisting symptoms (6%, Exp(B) = 0.428, p = .003) and overall shorter recovery duration (mean days = 12.48, 95% CI = 9.26-18.27) than female athletes from the hospital-based clinic.

Conclusions: The study provides evidence that biological sex is a determinant of recovery duration and symptom persistence in adolescent SRC, with females at a disadvantage compared to males. However, healthcare accessibility mitigates these sex-based differences, comparable to findings in collegiate athletes. Findings underscore the importance of personalized care and early access to comprehensive rehabilitation in managing SRC, considering both the biological and socio-environmental factors influencing recovery.

Introduction: Most adolescents experience a major reduction in symptoms and favorable improvements in clinical presentation over the first two-weeks following concussion. Electroencephalography (EEG) detects alterations in brain electrical activity post-concussion and has been shown to differ based on factors such as age and sex; however, it is unknown if EEG features change over time in the subacute period of concussion recovery. Our objective was to determine if EEG features differ in adolescents with concussion based on days between the injury and EEG evaluation.

Methods: This is a secondary analysis of a prospective cohort study. Adolescents with concussion were recruited from the Montreal Children’s Hospital Pediatric Emergency Department. Participants completed a resting-state EEG within the first 10 days following their concussion. Resting-state EEG was recorded in eyes-opened and eyes-closed conditions using a dry, 19-channel EEG headset (DSI-24, Wearable Sensing) for 5-minutes per condition. A comprehensive suite of EEG features, including spectral power, permutation entropy, functional connectivity, and graph theory features, were extracted in the delta (1-4Hz), theta (4-8Hz), alpha (8-13Hz), and beta (13-30Hz) frequency bands. A subset (n=10) of EEG features, which are the top features to accurately differentiate between healthy children and children with acute concussion, were evaluated in this study including delta power (F3, F4, F7, F8, & P4 electrodes), alpha power (F7 electrode), and beta power (O1, O2, Pz, & T6 electrodes). Separate linear regression models were conducted with days since concussion as the independent variable and a single EEG feature as the dependant variable. A Bonferroni correction was implemented to reduce the risk of Type I error, setting the significance level to p=0.005.

Results: Thirty-four adolescents (12.9 ± 2.2 years, 20 males) participated. Average time between concussion and EEG assessment was 6.4 ± 2.2 (range-: 2-10) days. Days since injury did not significantly affect any EEG feature in adolescents with concussion. Frontal delta power in the eyes-opened condition came closest to reaching significance (p=0.02), with no other EEG feature obtaining a p-value less than 0.10. Multivariable models were not conducted, as no significant univariate results were observed.

Conclusions: While most children experience major improvements in symptoms and clinical presentation in the subacute recovery period, EEG outcomes remain largely stable over this period of time. Future studies should include healthy controls and longitudinal designs to fully comprehend how concussion affects electrical brain activity beyond the first 10 days after concussion. Understanding if alterations in brain activity ever return to normative levels after concussion and if EEG has potential to guide removal from sport and return to play could greatly improve clinical concussion management in the future.

Brain injury is a leading cause of child death and disability worldwide, with reports of three million children experiencing traumatic brain injury (TBI) annually (Dewan 2016) and millions more affected by other forms of acquired brain injury. Of these children, a subset experiences such severe injuries that arousal and awareness are affected, resulting in disorders of consciousness (DoC). While many children emerge from this state and demonstrate functional improvements, some children remain in a persistent state of unresponsive wakefulness or minimal consciousness. The 2018 practice guidelines on DoC counsel practitioners that “once a prognosis has been established that indicates a likelihood of severe long-term disability, clinicians must counsel family members to seek assistance in establishing goals of care” and that “clinicians must identify patient and family preference early and throughout provision of care to help guide the decision-making process for persons with prolonged DoC” (Giacino 2018). However, these conversations may not occur following the acute phase of injury.

This abstract (linked to submissions Conklin and Diliberto) introduces the idea of expanding the concept of “goals of care” and “decision-making process” beyond initial discussions of withdrawal of care and discharge disposition towards a focus on participation for individuals with DoC. This abstract will introduce the construct of participation and discuss existing literature in children following severe brain injury and adults with DoC.

The World Health Organization’s International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) defines participation as ‘involvement in a life situation’ (WHO 2001). Researchers have further specified participation as “attendance in activities and involvement while attending those activities” (Imms 2017), while others focus on the concept of engagement (Imms 2016). Imms defined Engagement as an “internal state, often described as having several components: cognitive, behavioral, and emotional.”

A scoping review of children with severe brain injury discussed the multiple challenges of reintegrating and engaging in meaningful participation, “with potentially detrimental effects on health and wellbeing” (Wales 2021). Camara-Costa found that seven years after severe TBI, participation restrictions in children were associated with severity of initial injury. Additionally, while there is no existing research on participation in children with DoC, a 2019 study in adults found that persons with severe TBI initially in a DoC state were “unlikely to participate in productive tasks, social endeavors, or activities outside of the home up to 5 years post-injury, even if functional independence was recovered” (Malone 2019).

With the knowledge of the challenges of fostering participation following severe brain injury, we ask the question - What does participation, involvement, or engagement look like in patients without or with limited external indications of cognitive, behavioral, or emotional outputs (submission Conklin)? How can we assess our success in fostering it (submission Diliberto)?

Introduction: Access to suitable housing is a key determinant of health. Individuals with traumatic brain injuries (TBI) have specific and unique housing needs that are often unmet, placing them at risk of experiencing housing instability. It is important to gain a better understanding of their housing reality to provide housing options that meet the needs of people with TBI and promote their housing stability.

Objectives: To provide a portrait of the housing situation of people with TBI in Quebec (Canada).

Methods: This descriptive study is conducted in collaboration with Connexion TCC.QC, which brings together 13 regional community organizations providing services to people with TBI. A questionnaire documenting the current housing situation (e.g., type of housing, housing costs, support and services received) and past housing situation (e.g., types and number of housing situations experienced) was developed with the partner. The data collection tools included a sociodemographic questionnaire, an adapted version of the Residential Environmental Satisfaction Scale (RESS), and the Identification of Risk for Residential Instability and Homelessness Tool (IRIS). To participate in the study, participants had to be aged 18 or older and live with the impacts of a moderate or severe TBI for at least 5 years. Participants were recruited with the support of the organizations, via their social media, during activities offered by the organizations, and through reference from professionals. Descriptive statistics were performed on the collected data.

Results: One hundred participants with an average age of 51.9 years (SD = 14.0) were recruited from nine administrative regions of Quebec. Most of the participants were men (66%) and lived in an apartment or condo (37%), a house (36%), or a residence for seniors (8%). On average, participants have lived in 2.8 different places since the onset of their TBI (SD = 2.8). Based on the IRIS screening, 4% of participants were in an unstable housing situation. The majority of participants were generally satisfied with their current housing (82%), particularly with the practicality of their home’s layout (81%) and its maintenance (86%). When asked about their intention to move, 16% of the participants indicated that they did not plan to remain in their current housing in the next two to three years.

Conclusion: Housing situations vary greatly from one person to another. For some people, their current housing may not fully meet their specific needs. This study results could guide the development of innovations to better address the housing needs of individuals with TBI.

Background: Military service members and veterans (SM/V) may be exposed to repeated blasts during service, potentially resulting in traumatic brain injury (TBI). Mild to moderate TBI may result in chronic symptoms such as cognitive and vestibular impairment and affective dysregulation. We correlated affective measures with brain functional connectivity in SM/V with a sentinel blast injury presenting for mild TBI treatment.

Methods: A total 50 male participants including 26 SM/V with blast injury (mean 10.1yr since sentinel injury) and 24 healthy controls participated in this IRB-approved study. SM/V inclusion criteria included self-report of a sentinel blast exposure marking the onset of chronic symptoms. MR imaging was conducted on a 3T Siemens Prismafit MRI with 32-channel head coil. Acquisitions consisted of T1-weighted, 3D-multiecho MPRAGE images with inversion recovery6 and T2*-weighted, simultaneous multislice (SMS)-EPI resting-state functional MRI (rsfMRI, 7min 30sec run). Resting-state functional MRI (rsfMRI) data was subjected to minimal preprocessing in the CONN Toolbox. Multivoxel pattern analysis (MVPA) was conducted to localize voxel clusters which differed in whole-brain connectivity as a function of depression (Beck Depression Index, BDI), anxiety (Beck Anxiety Index, BAI), PTSD (PCL-5 Checklist), and/or vestibular function (Vestibular/Ocular Motor Screening, VOMS) and was followed by ROI-ROI connectome analysis (general linear model) to estimate differences in connectivity among suprathreshold ROIs as a function of group, BDI, BAI, PCL-5, or VOMS.

Results: PCL-5 was correlated with connectivity between prefrontal areas (PFcm and PF complex) and the postcentral somatosensory area 2. BAI was correlated with connectivity between regions associated with vestibular function (primary somatosensory area 3, vestibular nuclei complex, parieto-insula vestibular cortex, PIVC). Both BAI and BDI were correlated with connectivity between the caudal vestibular cingulate area 23 (CSv) and other areas (dorsolateral middle temporal area 37, posterior insular complex, area PFcm, primary somatosensory area 2). VOMS was correlated with vestibular regions (parieto-insular vestibular cortex/OP2, vestibular nuclei complex) and dorsolateral middle temporal area 37.

Discussion: Connectivity between areas associated with cognitive, affective, and vestibular function correlate with clinical measures of anxiety, depression, and PTSD. Regions associated with multisensory processing (PIVC) and perception of self-motion (CSv), shown to correlate with vestibular dysfunction after mTBI, were correlated with BDI and BAI in this chronic SM/V cohort. These findings may contribute to the observed relationship between chronic vestibular symptoms (including after mTBI) and emotional dysregulation and inform strategies for neurorehabilitation.

Background: Sleep disturbances are a common issue following mild traumatic brain injury (TBI), both in the acute phase (0-4 weeks post-injury) and the chronic phase (1-3 months post-injury). Given the strong connection between sleep and overall health, these disturbances may slow down or worsen the recovery of post-concussive symptoms. Although addressing sleep issues seems essential, it is unclear which individuals are most likely to benefit from targeted interventions.

Aim: This study aimed to explore the relationship between sleep-wake patterns and the recovery of post-concussive symptoms during both the acute and chronic phases of mild TBI. Additionally, it sought to assess the feasibility and acceptability of a sleep hygiene intervention for individuals experiencing ongoing symptoms in the chronic phase.

Methods: The study included 56 adult participants (aged 18-64) who had been diagnosed with mild TBI and were recruited shortly after being seen in the emergency department of a level I trauma center. Participants wore a wrist actigraph for 7 consecutive days and nights to monitor their 24-hour activity-rest cycles during both the acute and chronic phases. They also kept a sleep diary and completed self-reported questionnaires on sleep quality (Pittsburgh Sleep Quality Index, PSQI) and post-concussive symptoms (Rivermead Post-Concussion Questionnaire, RPQ) at both phases. After the second assessment, participants with a PSQI score indicating significant sleep disruptions (≥ 5) were offered a sleep hygiene intervention. This intervention consisted of a 90-minute educational session to create a personalized sleep plan, followed by two weeks of psychosocial support via phone calls. A follow-up assessment was conducted after the intervention.

Results: The average total sleep duration was 7 hours and 7 minutes in the acute phase and 6 hours and 47 minutes in the chronic phase. However, 41% of participants in the acute phase and 49% in the chronic phase slept less than the recommended minimum of 7 hours. Perceived sleep quality indicated impairments in 88% of participants during the acute phase and 77% during the chronic phase. Poor sleep quality was associated with higher post-concussion symptom levels in both phases (r=0.361 at one month, r=0.474 at three months, p<.01). While actigraphy data did not show significant associations with symptom levels in the acute phase, in the chronic phase, total sleep time was significantly correlated with symptom levels (r=0.319, p<.05). Of the 29 eligible participants, 16 completed the intervention, and 50% showed a ≥ 20% improvement in their PSQI scores. Non-responders had significantly higher post-concussion symptoms compared to responders (p<.001).

Significance: This study underscores that many adults do not meet recommended sleep duration following a mild TBI and that poor sleep quality is linked to higher symptom levels. A sleep hygiene intervention may be beneficial for individuals with mild to moderate symptoms.

Background: Social, economic, and systemic factors contribute to health disparities. However, there is relatively little research on these social determinants of health (SDoH) in the context of concussion, particularly in Canada. We aimed to identify the relationships between several SDoHs (i.e., racial/cultural identity, access to primary care, immigration status, and household income) and concussion incidence among adolescents and adults in Canada.

Methods: Data was collected from the Traumatic Brain Injury Rapid Response module of the 2020 Canadian Community Health Survey, administered by Statistics Canada. This is a cross-sectional, national health survey of 18,858 residents aged 12 years and older. Participants were asked whether they sustained a concussion (diagnosed by a medical doctor or identified by another health professional) in 2019. Respondents were also asked about several SDoH, including their racial or cultural identity, whether they have a regular healthcare provider, country of birth (used for determining immigration status), and their household income.

Results: A total of 245 participants self-reported at least one diagnosed concussion in 2019. In the unadjusted models, respondents who identified as Indigenous were more likely to report 1+ concussions compared to respondents who identified as White (OR=2.21, 95% CI=1.11, 4.39). Participants who identified as non-White were less likely to report having sustained concussion(s) compared to those who identified as White (OR=0.31, 95% CI=0.15, 0.65). Immigration status was also a significant predictor of experiencing concussion(s), with immigrants having reduced odds compared to Canadian-born respondents (OR=0.35, 95% CI=0.19, 0.65). Relative to those earning between $60,000 and $149,999 per year, participants earning >$150,000 were more likely to report having sustained at least one concussion (OR=1.65, 95% CI=1.06, 2.58). In the multivariable model adjusted for age and sex, including all SDoHs as predictors, only cultural group was significantly associated with having sustained concussion(s) in the past year (non-White
Conclusions: Several SDoHs were associated with differences in self-reported diagnosed concussion incidence. Prospective surveillance is needed to confirm these findings. Further research is also necessary to identify the mechanisms underlying SDoH-related differences in concussion risk.

Introduction: After moderate-to-severe traumatic brain injury (TBI), critically ill patients are admitted to the intensive care unit (ICU), where they often display agitated behaviours (e.g., aggression, akathisia, and disinhibition), referred as post-traumatic agitation. Post-traumatic agitation not only poses a substantial risk to the healthcare team but can also delay weaning from mechanical ventilation and ultimately hinder patient mobilization (i.e., participation in a rehabilitation program, independent living). Therefore, accurately assessing post-traumatic agitation in the ICU is crucial to ensure patient care that minimizes these risks. Comprehensive assessments of agitation have only been validated in inpatient rehabilitation settings, after the critical agitation period. However, no tool specifically designed to assess and monitor post-traumatic agitation has been validated during the critical period of agitation, which occurs in the ICU.

Objective: To develop a tool specifically tailored to assess post-traumatic agitation in ICU patients with moderate-to-severe TBI.

Methods: A Delphi method was employed to gather expert opinions. Eighteen experts (internist-intensivist, neurosurgeon, nurse, pharmacist, physiotherapist, physiatrist, psychiatrist, respiratory therapist) from various level-1 trauma centers were recruited. Inclusion criteria included having at least five years of experience treating TBI patients and regular exposure to patient post-traumatic agitation. Participants completed a questionnaire regarding their perception of post-traumatic agitation. An in-depth analysis of available instruments to assess post-traumatic agitation was also conducted. A prototype of the tool was developed based on the questionnaire responses and analysis of previous measures. It consists of 10 items representing specific manifestations of post-traumatic agitation, each rated by frequency (1 = almost never, 3 = often) and intensity (1 = disturbing, 4 = dangerous). Frequency and intensity scores are multiplied and summed for a total score out of 108. The tool also tracks interventions (environmental, physical, and chemical), with each targeted behaviour identified by a letter. Nine of the experts participated in a focus group to provide feedback on the prototype, which was revised following experts’ feedback and put to a final vote by the same experts.

Results: Questionnaire responses revealed a lack of consensus on onset (e.g., at trauma, while extubating) and duration of post-traumatic agitation, with estimates ranging from hours to weeks. Eighty percent agreed post-traumatic agitation assessment should measure both behaviour frequency and intensity. Eighty percent disclosed using the Richmond Agitation-Sedation Scale, a tool designed for sedation titration that does not fully capture post-traumatic agitation, to assess post-traumatic agitation. Questionnaire and focus group data uncovered ten different post-traumatic agitation behaviours. Consensus was attained for all items, with ≥ 80% agreement in the final vote.

Conclusion: We propose a novel tool developed to comprehensively assess post-traumatic agitation, accounting for the frequency and intensity of behaviours. A pilot study will validate the prototype, adjust items as needed, and verify its predictive validity.

Mild traumatic brain injury (mTBI) results in a cascade of symptoms, from motor coordination problems to light sensitivity, and headache. For most people, the majority of the symptoms resolve themselves over a few days or weeks. However, it has been well established that many symptoms may last for many months and longer depending on the severity and number of previous injuries sustained. These longer lasting symptoms include memory problems and executive dysfunction and often are associated with lasting frontal lobe processing issues. The current study aimed to evaluate the lasting impact of mTBI on frontal lobe function and examine the effectiveness of transcranial direct current stimulation (tDCS), at remediating those symptoms. A sample of young adults with and without a history of mTBI were recruited and evaluated using cognitive/behavioral tests that implicate an increasing demand on the frontal lobe. Cognitive tests included common frontal engaging tasks such as the Iowa Gambling task, a Go No-Go task, and multiple response inhibition tasks. Prior to testing, half of the participants, both with and without mild traumatic brain injury were given a single 20 minute tDCS treatment session prior to their frontal lobe assessment and the other half were given a sham tDCS procedure to eliminate expectation effects. Comparisons in task performance, both response time, accuracy, and overall performance were conducted. Results demonstrate that individuals with a history of mTBI show alterations in performance on frontal lobe demanding tasks. These changes are demonstrated for as long as 3 years after injury. Also, tDCS may alter those dynamics differentially depending on the participant’s brain injury status. The results suggest that the frontal lobe functioning of individuals with a history of mTBI is altered even after other symptoms resolve. Additionally, although tDCS may provide some hope as a treatment to alleviate these symptoms, individuals suffering from mTBI may require more tDCS sessions than controls to show improvements.

Concussion represents a public health concern given its incidence and the significant proportion of patients developing persistent post-concussive symptoms (PPCS). While electrophysiology and neuroimaging studies show promise in identifying brain function changes, the pathophysiology of PPCS remains unclear.
This study aims to bridge this gap by integrating behavioral assessments with complementary functional magnetic resonance imaging (fMRI) and high-density electroencephalography (HD-EEG) data in patients with PPCS. By leveraging the strength of both modalities, we hope to achieve a more comprehensive understanding of the neural dynamics underlying PPCS. We plan to include 80 patients diagnosed with a concussion based on medical evaluation and with PPCS as signified by a Rivermead Post-Concussion Symptoms Questionnaire (RPQ) score of 16 or higher.
Our outcome measures included 3T fMRI and 128-channel HD-EEG recordings in patients with PPCS, alongside behavioral assessments encompassing Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Beck Depression Inventory (BDI). The fMRI analyses focused on thalamocortical connectivity, while HD-EEG focused on whole-brain power spectrum and peak frequency analyses. Additionally, RPQ scores were correlated with fMRI findings, with age and sex as covariates. Data from the patient group were compared to an age-matched control cohort who underwent identical examinations. In our preliminary sample, thirty-four patients (9 males, mean age: 39y.±11.4) with PPCS (RPQ: 40.4±12.5) were recruited between 1 to 12 months post-injury (median: 91 days [59–186]). Twenty-five controls (15 males, mean age: 38.7y.±12.8) were also included. Behavioral assessments revealed that, on average, patients scored at or above the clinical thresholds on the BDI (mean ± SD: 17.3±8.7; threshold = 10), PSQI (11.4±3.9; threshold =5), and ESS (median [IQR]: 9 [5.5-14]; threshold = 9). These scores were all significantly higher than those of the control group (p < 0.001), which had RPQ (0 [0–2]), BDI (2 [0–4]), ESS (6.5±3.5), and PSQI (4.1±2.3). fMRI results indicated increased connectivity in patients between the left thalamus and precentral gyrus (p-FDR=0.023), as well as between the left ventral anterior nucleus and the lateral occipital cortex (p-FDR<0.001), precentral gyrus (p-FDR<0.001), lingual gyrus (p-FDR=0.006), cuneal cortex (p-FDR=0.027), and postcentral gyrus (p-FDR=0.03). Additionally, RPQ scores showed moderate positive correlations between the right ventral anterior thalamic nucleus and both the intracalcarine cortex (p-FDR=0.007) and lateral occipital cortex (p-FDR=0.032). EEG power spectral analysis suggests a shift towards lower frequencies for patients, who more often showed a main alpha peak closer to the theta range, although this difference was not significant. In contrast, higher frequencies (i.e., beta), were more prominent in controls compared to patients (p=0.015).
These results confirm previously published behavioral patterns of patients with PPCS and further highlight the potential role of thalamocortical dysfunction in PPCS while underscoring the utility of integrating fMRI and HD-EEG in understanding its pathophysiology.

Objectives: Four case presentations of patients with behavioral disturbances associated with waking up or going to sleep after msTBI.

Background: Sleep disturbance after acquired brain injury is highly prevalent with some estimates putting its prevalence at > 80% on admission to an acute inpatient rehabilitation unit. In a 2005 study Baumann and colleagues found significantly lower levels of hypocretin/orexin in the CSF of patients with moderate to severe traumatic brain injury in an acute trauma center. They also found that lower levels of hypocretin/orexin correlated with deeper states of unresponsiveness. This neuropeptide is generated in the posterior lateral hypothalamus and is thought to be critical in the “Flip/Flop Switch” model of sleep and wake cycles proposed by Saper and colleagues. In the past two decades hypocretin/orexin has been found to be either extremely low or even absent in patients with Type 1 and Type 2 Narcolepsy a clinical syndrome the hallmarks of which rest in having indistinct boundaries between states of Rapid Eye Movement (REM) sleep and wakefulness. The porous demarcation between these states leads to the remarkable clinical phenomena associated with this neurologic disorder such as cataplexy, hypnopompic or hypnogogic hallucinations, and sleep paralysis. REM Sleep Behavior Disorder (RBD) has also been described in patients with narcolepsy.
Results/Discussions: Four case studies of patients on an inpatient rehabilitation unit after msTBI are presented. All four appear to have marked difficulty distinguishing between dream and waking state. It seems reasonable to describe this as a ‘transition state disorder’ specific to emergence from msTBI. Two patients with extreme agitation had many characteristics of RBD with violently acting out adversarial dream state behavior. The other two patients more closely resembled subjects coming out of either hypnopompic or hypnogogic states with bizarre delusional reality systems and marked confabulation.
In this presentation, we describe the syndromic profile of these four patients and propose a classification system that could help the clinician identify similar patients with this syndrome. Established diagnostic criteria for transition state disorder after traumatic brain injury will help us better understand the prevalence of this disorder in this patient population as well as help the development of appropriate treatment strategies. The authors will also provide a rational neuropharmacological approach to this syndrome.

Background: Vibroacoustic stimulation therapy can support autonomic function through enhanced sympathetic/parasympathetic balance. Autonomic dysfunction is a key pathophysiological pathway underlying persisting post-concussion symptoms (PPCS). Therefore, any treatment that can effectively address autonomic dysfunction should help remediate PPCS.

Objectives: Our study examined the efficacy of a wearable vibroacoustic stimulation device (VSD) for remediating PPCS pathology and improving functional outcomes.

Methods: Patients at a pediatric concussion clinic presenting with PPCS were offered the VSD as an adjunct to standard care for six weeks. Control participants (n = 25) received standard care alone and were matched to the VSD group (n = 25) on demographic and concussion injury variables. Participants completed an assessment battery pre- and post-intervention, consisting of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), Beck Depression Inventory (BDI), Behavioral Rating Inventory of Executive Function (BRIEF), Neurological Quality of Life (Neuro-QoL) sleep and fatigue scales, Vestibular Ocular Motor Screening (VOMS), Cogstate testing battery, and heart rate variability (HRV). The Cogstate battery included the Groton maze task and one- and two-back working memory tasks. HRV was recorded during rest, deep breathing, and isometric handgrip contraction. HRV reactivity (ΔHRV) was calculated by subtracting the deep breathing condition from handgrip contraction. In accordance with prior literature, participants with positive pre-intervention ΔHRV values were classified as having autonomic dysfunction (DYS+). Statistical analyses consisted of 2 (time: pre/post-intervention) by 4 (group: VSD-DYS+, VSD-DYS-, Control-DYS+, Control-DYS-) mixed ANOVAs with post hoc Bonferroni-corrected t-tests for significant results.

Results: Eleven VSD participants and 13 Controls displayed pre-intervention autonomic dysfunction. There was a significant group x time interaction for ΔHRV, whereby the VSD-DYS+ group exhibited a decrease in ΔRMSSD pre- to post-intervention (d = 1.00, p = 0.032), while the other groups did not (VSD-DYS-: d = 0.40, Control-DYS+: d = 0.12, Control-DYS-: d = 0.27, p’s ≥ 0.624). There was also a significant interaction for the one-back, with the VSD-DYS- group exhibiting increased accuracy pre- to post-intervention (d = 0.96, p = 0.012), while the other groups did not (VSD-DYS+: d = 0.74, Control-DYS+: d = 0.06, Control-DYS-: d = 0.28, p’s ≥ 0.132). There were no significant group differences in resting HRV, maze learning/recall, nor symptoms assessed by the RPQ, BDI, BRIEF, Neuro-QoL, or VOMS (p’s > 0.05). Average daily minutes of VSD use was correlated with change in resting HRV metrics (r’s ≥ 0.42, p’s ≤ 0.036), but not with the remaining functional or symptom measures.

Conclusions: Our results provide preliminary evidence that vibroacoustic stimulation therapy may support the recovery of PPCS via enhanced cardio-autonomic function and improved working memory. Furthermore, those who benefit the most appear to be those with significant autonomic dysfunction.

Background: Approximately 10% of all children and youth (≤ 18 years) have a neurodevelopmental disorder (NDD) such as autism spectrum disorder, attention-deficit/hyperactivity disorder, or learning disabilities. Individuals with a NDD are more likely than their neurotypical peers to experience a concussion and are at a greater risk of persisting symptoms after a concussion. Across youth that experience a concussion, the proportion with a co-occurring NDD can be as high as 34%. Despite calls for more inclusive concussion guidelines, there is a dearth of studies focused on youth with a NDD who experience a concussion, limited knowledge about their experiences or outcomes, and no clinical guidelines for concussion management that considers the unique needs of these individuals.

Objectives: To describe the clinical presentation and services accessed by children and youth with a NDD who experience persisting symptoms after a concussion.

Methods: This study will include a retrospective chart review of health outcomes and service utilization (i.e., continuity, comprehensiveness, accessibility, and productivity) for children and youth with a NDD seen in the Persistent Concussion Clinic (PCC) at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Ontario from July 2015 to August 2023. The PCC is the only publicly funded interdisciplinary clinic in Ontario for children and youth experiencing persisting symptoms after a concussion. Information related to demographics (e.g., age, sex, medical history), setting of concussive injury, and service utilization (e.g., disciplines accessed, number of appointments) will be extracted for clients with and without a NDD. Descriptive statistics will be used to describe demographics and service utilization. Additionally, t-tests and ANOVA (p< 0.05) will be used to compare service utilization between clients with and without a NDD.

Results: Over 700 charts will be included in the retrospective chart review with approximately 20% of these children and youth reporting a NDD upon entrance to the PCC. This is likely a conservative estimate as clients may have an undiagnosed NDD or receive developmental diagnoses or referrals while working with the clinical team. Additional analyses are ongoing.

Conclusions: Children and youth with a NDD who experience a concussion are an underrepresented and often overlooked group, with no clinical guidelines describing how to best support them. As the PCC is a unique clinic, anticipated results will shed light on health outcomes and service utilization for children and youth with a NDD who experience persisting symptoms after a concussion. Better understanding the needs of this population will provide initial contributions to clinical recommendations, ultimately addressing gaps in care.

Objectives: Clinicians require guidance to aid patients attempting to return to work (RTW) after concussion. This systematic review synthesizes the results of interventions to determine what types of interventions (i.e., early education and intervention, psychological, rehabilitative, interdisciplinary) are effective, and what behavior change techniques (BCTs) are most frequently used and which BCTs are most promising.

Methods: Peer-reviewed adult concussion intervention studies of any design with direct (e.g., RTW status) or indirect RTW (e.g., community integration) measurements were included. Studies were excluded if they reported on populations with less than 100% with a concussion, or were not interventions published in peer-reviewed journals. MEDLINE ALL, PsycINFO, and CINAHL databases were searched for literature published January 2000-end of December 2023. To assess methodological quality, the Downs and Black checklist was used because it is appropriate for the assessment of both randomized and non-randomized studies of health care interventions. A narrative review describes the effectiveness of intervention type. For BCTs, frequency of BCTs used in the experimental conditions is provided. Also, promise ratios were calculated to establish which BCTs are most effective.

Results: 16 documents were included for data extraction. The majority of the studies had an intervention condition and a comparator condition (12/16), sample sizes ranged from 35 (one group studies) to about 80 per group in multi-group studies, the average age per group was about 40, and the studies were well-balanced regarding sex proportions. Psychotherapy, neuropsychological training, vestibular rehabilitation, vision rehabilitation, exercise, compensatory strategies, cognitive training, vocational support, and interpersonal training may be efficacious. The BCT information about health consequences was frequently used in experimental conditions. Effective BCTs were instruction on how to perform the behavior, reduce negative emotions, action planning, information about health consequences, and problem solving.

Discussion: Limitations of this review include heterogeneity regarding study design (e.g., 7 studies did not use randomization, different dosages and follow-up time frames), 11 studies had moderate risk of bias, and some of the interventions were not designed to facilitate RTW, but rather RTW was a secondary measurement outcome. Despite the limitations, this review is the first to explore interventions to help people with concussion to successfully RTW. It is hoped that the promising interventions and intervention components identified are considered by practitioners when working with patients to improve the quality of their lives (PROSPERO: CRD42022384151).

Background: Acquired brain injury (ABI) is the leading cause of disability and death among children worldwide. ABI can result in cognitive, behavioural, emotional, physical, and communication difficulties. The lack of supports provided to children/youth, and families post-ABI often leaves the primary support of students with classroom educators. Unfortunately, educators are largely underprepared to accommodate the learning needs of students with ABI. To address this critical gap in educator learning, Dr. Scratch and an interdisciplinary team created an e-learning module, titled TeachABI, to enhance educator understanding of ABI symptoms observed in students post-ABI, in addition to providing educators with strategies that can be implemented for students post-ABI. Quantitative pilot testing of TeachABI revealed that the completion of the module resulted in improvements in ABI knowledge and confidence among educator participants, that were maintained at 2-months post-training. However, it remains unknown how the completion of the TeachABI module may impact educator understanding of ABI knowledge and the implementation of strategies for students with ABI in the classroom.

Objectives: To examine how the completion of TeachABI impacts educator understanding of implementing ABI-specific knowledge and strategies for students with ABI in the classroom.

Methods: 29 participants fluent in English, and either working as a certified educator in Ontario or enrolled in an Ontario Teacher’s College program participated in this study. Throughout pilot testing, participants completed the TeachABI module and then participated in semi-structured exit interview via Zoom. A deductive content analysis approach was used whereby the Theoretical Domains Framework (TDF) was the guiding theory to identify key concepts during the coding of initial categories. Data that could not be categorized into pre-existing categories within the TDF were also identified throughout the analysis.

Results: Common themes that emerged throughout participant interviews included knowledge of ABI (i.e., reinforcing previous knowledge, and new knowledge of ABI and ABI strategies), beliefs about educator capabilities (i.e., increased confidence following module completion), environmental and social facilitators and barriers to implementing ABI strategies (i.e., number of students in the classroom, physical classroom space, resources available through the school and/or school board, school team, etc.). In addition to TDF domains, general module feedback and implementation of TeachABI feedback were coded as additional themes emerging throughout interviews.

Discussion: The results highlight educators’ increased confidence and understanding of ABI knowledge and strategies to implement within the classroom. The results demonstrate that TeachABI is an effective tool for increasing ABI-specific knowledge and strategies for educators. The module feedback has been implemented into future iterations of TeachABI. Future research should trial the implementation of TeachABI into the hospital to return to school pathways for students post-ABI in addition to creating pathways for educator completion of TeachABI across Ontario schools.

Individuals with mild traumatic brain injury (mTBI) can suffer from persistent (i.e., over 4 weeks after injury) post-concussive symptoms (PPCS) in about 30% of cases. PPCS affect various functional domains and are commonly evaluated using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), a self-report symptom rating scale evaluating the presence (cut-off score ≥16) and severity (total score 64) of PPCS. Motor learning reflects synaptic plasticity supported by excitatory (long-term potentiation) and inhibitory (long-term depression) mechanisms and is crucial for various daily tasks. It has shown to be decreased in patients and athletes following mTBI as compared to healthy controls. However, the potential interplay between PPCS and motor learning impairments remains scarcely investigated. The objective of this study is to quantify the relationship between PPCS severity and motor learning impairments in a subpopulation of patients diagnosed with mTBI through an institutional care pathway. Implicit motor learning was assessed using the serial reaction time test (SRTT), a computerized bimanual finger-tapping task using block sequences. After removing outliers, two learning indexes were computed for the dominant hand: the total training-related learning ((median reaction time of the first sequence block – median reaction of the last sequence block) / median reaction time of the first sequence block), reflecting both motor and sequence learning and; the sequence-specific learning ((median reaction time of the last sequence block – median RT of the last random block) / median reaction time of the last sequence block), reflecting sequence-specific knowledge only. These indices were correlated with RPQ scores using Pearson correlations. We included 18 participants (mean ± SD age: 39.0 ± 13.4 years, 12 females, median [IQR] time since injury: 90.5 [127.8] days). Their RPQ scores was 32.3 ± 12.8; 15 participants were above the PPCS threshold. Regarding motor learning, the mean group reaction time was 707.0 ± 214.3 ms for all sequence and random blocks (accuracy: 94.0 ± 4.4 %). The total training-related learning index was 7.3 ±10.2 % while the sequence-specific learning index was -8.6 ± 9.8 %. There was no significant correlation between RPQ scores and the total training-related learning index (r= 0.01, p=0.96) neither between RPQ scores and the sequence-specific learning index (r=0.48, p=0.052). This preliminary analysis suggests an absence of relationship between motor learning and PPCS severity, which could reflect the specificity of a motor learning assessment versus global information processing impairments (i.e., presence of implicit motor learning alterations in the absence of other neuropsychological problems). These findings would need to be confirmed on a larger sample that includes control participants. This currently ongoing work (a priori sample size estimation: 75 participants) will contribute to disentangling clinical and subclinical effects of mild traumatic brain injury and its impact on specific functions, such as motor learning.

Background: Accurate assessment of severely brain injured patients’ levels of consciousness and potential to recover underpins most crucial decisions but poses a major challenge for clinicians in the intensive care unit. The neurological wake-up test (NWT) is a widely used clinical tool which comprises a behavioral assessment following a short interruption of sedation. A good behavioral response during interruption of sedation has high positive prognostic value. However, the absence of a behavioral response has few negative diagnostic or prognostic value, as it may be caused by confounding factors ranging from sensory or motor impairments to pain and fatigue. We propose the brain’s electroencephalogram (EEG) response during interruption of propofol sedation as a clinical tool to identify neurophysiological signs of waking up to complement behavioral assessment during the NWT.


Methods: We recorded 128-channel EEG of 41 severely brain-injured patients during a clinically indicated NWT. Behavioral responsiveness was assessed using the Glasgow Coma Scale (GCS) before and during interruption of sedation. During the NWT, nine patients regained responsiveness, 13 patients showed ambiguous responsiveness, and 19 patients were not responsive. Brain response to sedation interruption was quantified using the dynamic change of EEG power, spatial ratios and the spectral exponent. The patients’ survival, recovery of responsiveness, and functional outcomes were assessed up to 12 months post-recording. Predictions on the patients’ functional outcome were provided by the attending physician. We trained a linear regression model to identify brain patterns related to a good behavioral response to the NWT. We then used the same model to identify a favorable reaction of EEG patterns in patients whose behavioral response was ambiguous or absent. Prognostic value was assessed using the Mann-Whitney-U test and the Area under the curve (AUC).


Results: Patients’ increase in arousal following sedation interruption was accompanied by changes in the EEG, most notably in the delta, alpha and low beta bandwidth and the spectral exponent. Using EEG signature during interruption of sedation in addition to behavior revealed a heterogeneity in patients, with some patients showing dynamically changing EEG patterns despite absent or ambiguous behavioral responsiveness. Compared to the observed change in behavior, predicting change in arousal based on patients’ EEG response increased the AUC from 0.64 to 0.74. EEG-based predicted behavioral response significantly distinguished patients according to survival (U = 83, p<0.05). Using the contrast of EEG patterns with and without sedation had higher prognostic value than using EEG features of a single state alone. Physician predictions of functional outcome were marked by a high level of uncertainty, which was maximal when patients show an ambiguous behavioral response.


Conclusions: Our results indicated that EEG features can complement behavioral responsiveness to provide clinicians a novel perspective on capacity of consciousness which goes beyond behavior.

Introduction: Individuals diagnosed with disorders of consciousness (DOC) after a brain injury represent a huge diagnostic challenge. Recent findings suggest that complementing bedside assessment with neurophysiological sensing and emotionally-valenced meaningful stimuli might contribute to improve diagnosis. This preliminary study examines the reliability of electrical brain responses of patients with DOC to passive stimulation using positively-valenced videos of acquaintances or strangers, with the goal of classifying patients as being in a minimally conscious state (MCS) or with unresponsive wakefulness syndrome (UWS).

Methods: Ten patients in minimally conscious state and 9 patients with unresponsive wakefulness syndrome participated in the study. A block paradigm alternating stimulation blocks, where participants visualized videos with emotional content, and resting blocks, was conducted. The stimuli included 6 videos of an acquaintance of the participants (a relative or friend) and 6 videos of a sex- and age-matched stranger describing positive experiences and traits either of the participants or another person, respectively. Brain activity was recorded using a 32-ch EEG headset. Differential entropy, power, wavelet energy, fuzzy entropy, and permutation entropy were calculated for all frequency bands and electrodes. Linear SVM classifiers were trained to distinguish the diagnosis of the patients. Different models were obtained based on the type of stimuli (videos of an acquaintance or a stranger) and the EEG feature used, all aiming at classifying patients in MCS or with UWS. The performance of the models were compared.

Results: The highest AUROC classification performance was achieved using fuzzy entropy as a feature, with scores of 0.90±0.05 for videos of an acquaintance and 0.80±0.06 for videos of a stranger. This was followed by wavelet energy (0.73±0.10 and 0.73±0.04), permutation entropy (0.68±0.04 and 0.66±0.05), differential entropy (0.64±0.03 and 0.59±0.01), and power (0.61±0.04 and 0.61±0.01) for models trained on videos of an acquaintance and a stranger, respectively.

Conclusions: Machine learning models achieved higher performance in classifying patients with DOC as in MCS or with UWS when the models were trained on EEG registers while viewing videos of an acquaintance, compared to videos of a stranger. The largest performance differences between stimuli types were observed with fuzzy entropy and differential entropy. Among all features, models using fuzzy entropy consistently showed the highest performance, regardless of the type of stimulus. The superior diagnostic performance with acquaintance videos suggests the potential diagnostic value of this stimulus type. The diagnostic approach used in this study could be a promising tool to complement DOC diagnosis and warrants further investigation in future research.

Acknowledgments: 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).

Objective: The objective of this presentation is to describe the empirical development of training competencies, organized across six domains (knowledge, screening, eligibility, assessment, intervention, and community reentry), for service provision to justice-involved youth experiencing a brain injury. We will detail each phase of the process and discuss dissemination strategies and suggestions for use in practice.

Significance: Community reentry outcomes for formerly incarcerated youth are significantly worse for youth with brain injury than for their peers without disabilities. Research has illustrated that youth with brain injury in juvenile corrections are not receiving the support they need to achieve positive outcomes, possibly because most staff in juvenile correction facilities lack the knowledge and skills they need to adequately support these youth. To address the urgent need for staff training on evidence-based practices that can successfully improve the transition and life outcomes of justice-involved youth who experience brain injury, we developed a set of professional development training competencies for correctional staff in supporting these youth. This was done through an exploratory research project designed to empirically define the training needs and core competencies that juvenile services personnel require to work successfully with justice-involved youth with brain injury and define professional development standards to address those identified needs.

Methods: Using stakeholder and community input, this research project was implemented across three phases. In Phase I, we conducted and analyzed data from a series of qualitative interviews of key stakeholders in juvenile corrections across the country. During Phase II, findings from Phase I data were used to develop a comprehensive training needs survey for nation-wide dissemination to juvenile facility personnel (e.g., counselors, teachers, residential staff, health care providers). Finally in Phase III, we used the focus group and survey results to conduct an iterative Delphi survey procedure to identify empirically based competencies for training correctional staff working with youth with brain injury in correctional settings.

Results: This process resulted in a set of 44 training competencies split among the six domains of (a) knowledge, (b) screening, (c) eligibility, (d) assessment, (e) intervention, and (f) community reentry. The Delphi process also determine which competencies were most relevant and important for which roles in juvenile settings, including administration, line staff, education staff, residential staff, behavioral health staff, physical health staff, vocational staff, and parole and probation staff. Each phase of the process will be shared as well as the resulting competencies and dissemination plan. Attendees of this session will understand the need of youth with brain injury in correctional settings, understand the process of developing training competencies for staff within correctional settings on supporting youth with brain injury, and understand strategies for implementing these training competencies in practice.

Significance: Children have the highest rate of emergency department visits for traumatic brain injury (TBI) of all age groups. An injury of any severity to the developing brain can disrupt a child’s developmental trajectory and may result in restrictions in school classwork requirements and participation in activities such as sports and extracurricular clubs and projects. As a result of a TBI of any severity, children may experience changes in their health, thinking, and behavior that affect learning, self-regulation, and social participation which are important in becoming a productive adult.

Objectives: The objective of the Return to School project, funded by the Centers for Disease Control and Prevention, is to evaluate the efficacy of a Return to School (RTS) model in Oregon. The primary aim of the research is to compare the effectiveness of the Oregon RTS model to treatment as usual in Ohio in improving health, educational, and social outcomes for students in grades K-12 who have experiences TBI of any severity compared to students who have no formal RTS programming. A second aim was to measure the implementation and fidelity of the COR-TBI program with a third aim to understand the implementation levers if the program is deemed effective.

Methods: COR-TBI uses a quasi-experimental comparison group design using propensity matched scoring. The IRB-approved protocol includes electronic survey administration of parent, student, and teacher measures on the social, behavioral, and health outcomes of students experiencing a TBI. This presentation focuses on the specific academic, social, and health functioning for 721 (425 treatment and 296 business as usual) school-age children and adolescents at the time of study enrollment. Recruitment was between Fall 2020 through Spring of 2024 with data collection ending summer of 2024. A qualitative component utilizing virtual interviews and focus groups collected in 2023 with key stakeholders of parents, students, teachers, school, and community health care providers. Thematic analyses were completed. Based on formative findings from the focus group and interview data, a nationwide survey of school principals/asst. principals is being conducted in spring 2024 to further understand the knowledge, attitudes, and practices of school principals relative to serving students experiencing TBI in K-12.

Results: At the time of the presentation, we will have conducted the outcome analyses on the quantitative aim to measure the efficacy of the COR-TBI program. School principal survey data will also be analyzed and ready to share at the time of the presentation. Medical provider interviews defined multiple themes to better understand how schools, families, and the medical community can collaborate to ensure students are provided the needed school accommodations following a TBI event. Lessons learned from the study along with implications for schools and medical providers will be shared.

Background: There is growing recognition that illness beliefs are related to symptom burden after concussion and provide a target for treatment. Studies have shown that changes in illness beliefs are possible although it is not clear if this relates to a reduction in concussion symptoms. This study examined the relationship between illness beliefs and changes in concussion symptoms during a multidisciplinary concussion treatment program.

Methods: A retrospective observational design was used to examine data from an outpatient multidisciplinary treatment clinic for delayed recovery after concussion from 2015-2024. Treatments included rehabilitation medicine, psychology, physiotherapy, exercise physiology, occupational therapy, speech pathology, and dietetics. Inaccurate or unhelpful illness beliefs about concussion were generally targeted by all therapists using psychoeducation, and specifically by psychologists using approaches such as cognitive behaviour therapy. Participants were included in the analysis if they had completed admission and discharge measures of symptoms using the Post Concussion Symptom Checklist (PCSC), and the Brief Illness Perception Questionnaire (BIPQ) at least once on admission. Regression analyses examined the relationship between illness beliefs and reduction of symptoms across treatment whilst controlling for a range of covariates including demographics (e.g. gender, age), injury characteristics (e.g. time since injury) and co-occurring symptoms (e.g. depression, anxiety).

Results: Data was available for 374 participants. Of the sample, 54% were female with mean age of 38.6 years, and admission to the treatment program was on average 197.6 days post concussion. Treatment period was on average 192.9 days, with mean symptom scores on PCSC reducing from 55.3 on admission to 26.6 on discharge. Regression analyses showed that baseline illness beliefs on BIPQ (total and domain) were not related to the symptom reduction from admission to baseline. In contrast, using a subset of 231 participants who completed BIPQ at baseline and discharge showed that negative illness beliefs significantly reduced across the treatment period, and reduction in negative illness beliefs on BIPQ was related to greater reduction in symptoms on the PCSC.

Conclusions: Changes in illness beliefs were related to concussion symptom reduction in a multidisciplinary clinic, however, baseline degrees of illness beliefs were not. This supports treatments for delayed concussion recovery that focus on changing illness beliefs, and that baseline levels of negative illness beliefs may not be a good predictor of treatment outcome. Controlled studies are needed to more rigorously examine the relationship between illness beliefs and concussion symptoms.

Background: Concussion following sports and other injuries is a growing concern in the community. General practitioners (GPs) are at the forefront of diagnosis and management of concussion although little is known about their practices in this role. This study used a survey to explore GP approaches to concussion management care, knowledge of relevant guidelines, and confidence in care.

Methods: A cross-sectional online survey design was used. The survey was designed with GP input and was disseminated to Australian GPs via websites and email lists for the Australian College of General Practitioners and local GP networks primarily based on Victoria. Descriptive statistics were used to explore survey findings, while associations between responses were examined using effect size calculation and chi-square significance testing.

Results: The survey was completed by 33 Australian GPs with on average 12 years of experience in working as a GP. The majority were based in the state of Victoria and in metropolitan settings, with more than half seeing 4-6 patients for concussion in the past 12 months and sports being the most frequent injury mechanism. Over 90% of GPs reported moderate or high levels of confidence in diagnosing concussions and providing initial advice and management, compared to about 40% for managing patients who are slow to recover from concussion. About 70% reported using clinical guidelines as a main source for guiding their concussion care, with varying approaches to practice reported. GPs primarily used clinical interview and neurological examination to assess for a suspected concussion, with balance testing and neck exam used frequently by about half, and standardised concussion tests (e.g. SCAT) or cognitive measures only used frequently by about one quarter of respondents. About half of the respondents recommend rest until patients were asymptomatic and that having a concussion was likely to cause longer term brain issues. The length of recommended rest after a concussion (e.g., 48 hours vs. until asymptomatic) was moderately linked to whether GPs relied on clinical guidelines as a primary information source. All participants indicated a desire for further training and education on concussion.

Conclusions: This pilot study highlights varying practices in relation to the GP assessment and management of concussion including the recommended period of rest after concussion. Delayed recovery after concussion was identified as a key challenge for GPs and there is a desire for further training. Future work will use interviews to unpack these findings which will inform subsequent surveys and concussion education needs for GPs.

The 2022 United Nations report indicates that up to 30% of women globally have experienced sexual and/or physical violence by their partner at least once in their lives. Previous studies (Black et al., 2011) report that nearly one in four women and one in seven men in the US reported severe physical violence (being hit, kicked, choked, beaten, burned, stabbed, or shot) by their intimate partner. Twenty-five percent of these women have experienced TBI and at least sixty percent have sustained more than one TBI with loss of consciousness. Women who experience Intimate Partner Violence (IPV) do not routinely seek health services for injuries (Davis, 2014) and although injuries to their face and head are common, when medical services are provided, TBI is often overlooked or minimized (Banks, 2007; Davis, 2014). Davis (2014) states, “The impact of TBI in abused women creates a multitude of sequelae that may or may not be recognized acutely but have long-term impact on health outcomes” (p. 301). Significantly, head injuries sustained by this study population are often unreported and left untreated; subjects have not been traditionally included in most clinical trials of putative neuroprotective or restorative drugs (e.g. Narayan et al 2002). IPV survivors often have deficits in higher brain function, common in the aftermath of brain injuries of all severities. Studies in humans with cognitive deficits, including aMCI and Alzheimer’s disease, report decreased glucose utilization in brain regions which play a crucial role in memory formation. Brain glucose metabolism plays a prominent role in TBI pathology; there is a close relationship between glucose metabolism and memory deficits in TBI and other pathologies such as Alzheimer’s disease, stroke and chemo brain. Glucose metabolism can be imaged with the specific tracer fluorodeoxyglucose F18 (18F] FDG). Drs. Monahan and Biegon are investigating the relationship between glucose metabolism and neuropsychological sequelae of TBI. Participants who sustained a traumatic brain injury emanating from physical battering from a domestic partner were identified and recruited directly from three domestic violence shelters in Suffolk County, New York, as well as other agencies serving domestic violence victim. Thus far, the study and neuropsychological test results of participants reveal large (IZI>1) deficits in verbal memory and attention/processing speed. Deficits in most other domains, including sustained concentration and executive functions, nonverbal analytical reasoning, nonverbal abstract problem solving, and inductive reasoning are noted. Scores on scales of depression, PTSD, and concussion outcome were also high for all women. In addition to the study results the author will discuss some of the challenges with recruiting and conducting this study.

Background: The eTherapy app was created through a collaboration of computer engineering and occupational therapy and was developed originally for patients with orthopedic injuries working on motor re-education. The app uses motion capture technology of a 9-axis Accelerometer Inclinometer Inertial Measurement Unit (IMU) to measure a range of motion. The IMUs are attached to the patient on both sides of a targeted joint and connect through Bluetooth to the Android mobile device with the app. A prior study using the expert opinion process identified a novel feature of the app in patients' status post-traumatic brain injury and experiencing visual tracking deficits.

Methods Researchers utilized a case study methodology with an expert opinion process to advance the app and add a feature designed to be used in intervention with post-concussive patients experiencing deficits in visual tracking and smooth pursuits. Researchers introduced the visual tracking feature to two occupational therapists specializing in concussion rehabilitation and demonstrated its capabilities. The therapist used the visual tracking feature with three patients who met inclusion criteria and logged and journaled on its utility before participating in a semi-structured interview.

Results: The visual tracking feature was added to the eTherapy app. In the smooth pursuit activity, an IMU sensor was attached to the patient's forehead, and the other IMU sensor was attached to the back of the patient's hand. Sensory feedback was provided when the forehead sensor was aligned with the hand sensor. Some difficulty existed with this app activity in function as the position of the hand sensor changed with the grasp required. The therapists proposed and implemented a second activity involving perceptual midline shift. This new activity resulted in valuable data documenting whether the patient could move the midline of their head to match the center of a diagram, where the second IMU was placed.

Conclusions: While the eTherapy application is still being developed, measuring movement, including velocity, smoothness, and duration, may be beneficial. The eTherapy app showed promise for visual motor integration in smooth pursuits but would need further development in protocol use in functional tasks. The app showed promise for use in the assessment and intervention of perceptual midline shift. The app is portable and inexpensive, making it appropriate for in-clinic and possibly home programming.

Background and Objectives: Traumatic Brain Injury (TBI) can lead to cognitive impairments and executive dysfunction, increasing the risk of incarceration and recidivism. TBI in childhood is especially concerning, as it is associated with long-term cognitive and behavioral issues, including memory deficits, attention problems, and behavioral difficulties, which may elevate the risk of criminal behavior. This study aims to examine the relationship between age at first TBI and behavioral outcomes in incarcerated males, with a focus on identifying patterns that could inform interventions to reduce recidivism.

Methods: Cross-sectional data from 108 males with TBI collected as a baseline assessment for a clinical trial. Participants were recruited 12 months prior to release. The Level of Service Inventory–Revised (LSI-R) is a structured interview for correctional populations used to predict recidivism risk, adjustment, and institutional misconduct.

Results: On average, participants reported more than three injuries with loss of consciousness (LOC). Seventy-one percent of the sample reported more than one TBI with LOC. Most offenders (n=76, 70.4%) reported their first TBI with LOC prior to the age of 18 with 50% (n=54) reporting an injury with LOC prior to the age of 15. Of the 54 participants with LOC prior to age 15, 59% were incarcerated prior to the age of 16 compared to 53% of the participants with LOC occurring after the age of 15. Those with earlier injuries had a higher rate of institutional misconduct (56%) and assault/violence charges (57%) than those with later injuries (44% and 43%) though these differences were not statistically significant. Results of the LSI-R showed that those with LOC before age 15 were significantly less likely to demonstrate acceptance of responsibility for their crime (χ²= 3.88, p=.049), less likely to show acceptance of their sentence (χ²= 11.33, p<.001), more likely to have friends involved with crime (χ²= 4.47, p=.035), and less likely to have successful employment history (χ²= 4.59, p=.032) than those injured later in life.

Conclusions: This study highlights the significant impact of early traumatic brain injury (TBI) on incarcerated males, particularly those who experienced their first injury before the age of 15. The findings suggest that earlier injuries are associated with increased rates of institutional misconduct and violent behavior, as well as lower levels of accountability and acceptance. Moreover, early TBI was associated with involvement in peer groups with criminal histories and reduced employment success, further hindering reintegration after incarceration. These results emphasize the importance of early intervention and tailored rehabilitation efforts for individuals with a history of TBI, especially in juvenile populations, to potentially reduce the risk of future criminal behavior and improve long-term outcomes. Future research should explore the development of specific coping and treatment strategies for this vulnerable group.

Background: Traumatic brain injury (TBI) is associated with cognitive, emotional, and functional sequelae. The ability to maintain psychological stability under stress is often described as resilience (Masten et al., 2021) whereas posttraumatic growth (PTG) is defined by positive psychological changes following adversity (Tedeschi et al., 2018) and both may be implicated in adjustment and recovery following TBI, yet their roles in neurorehabilitation are under-explored (e.g., Grace et al., 2015; Infurna & Jayawickreme, 2019). We examined resilience and PTG for adults adjusting to TBI and its sequelae.

Methods: A cross-sectional, mixed-methods design was conducted via online survey recruited through social media, healthcare support groups, and rehabilitation clinics. Questionnaires of sociodemographics, health history including TBI and standardized measures of trauma (Trauma Symptom Inventory-2; Core Beliefs Inventory), resilience (Connor-Davidson Resilience Scale), PTG (Posttraumatic Growth Inventory), functional, (Mayo-Portland Adaptability Inventory-4), and psychological outcomes (Symptom Assessment-45 Questionnaire, PTSD Checklist for DSM-5) were completed. Qualitative analyses will be reported elsewhere.

Results: 19% (n = 124; n = 669 screened) reported a history of TBI: at least one mild (n = 67, 54.0% i.e., see Silverberg et al., 2023), moderate (n = 33, 26.6%), or severe TBI (n = 24, 19.4%) with 87% requiring medical assistance (i.e., hospitalization). Leading causes of the TBIs were accidental falls (37.9%), sports-related injuries (15.3%), and motor vehicle collisions (14.5%). The sample (Mage = 52 yrs, SD = 17 yrs) was primarily Caucasian (77.3%), female (74.2%) and had completed postsecondary (82.2%). Analysis of variance (ANOVAs) indicated significant differences across TBI severity groups (mild, moderate, severe) for psychological trauma (CBI: F(2,121) = 14.34, p < .001; TSI-2: F(2,121) = 3.50, p = .034), functional outcomes (MPAI-4: F(2,121) = 17.94, p < .001), and psychological outcomes (PCL-5: F(2,121) = 7.15, p = .001; SA-45: F(2,121) = 5.74, p = .004). Tukey HSD analyses demonstrated persons with severe TBI endorsed significantly greater psychological trauma associated with the TBI event (CBI: severe vs. mild, p < .001; TSI-2: severe vs. mild, p = .039), poorer functional outcomes (MPAI-4: severe vs. moderate, p < .001), and greater psychological distress (SA-45: severe vs. mild, p = .004; PCL-5: severe vs. mild, p = .001) than those with less severe injuries. In line with theories of PTG, individuals with severe TBI endorsed significantly more PTG experience relative to those with mild injuries (PTGI: severe vs. mild, p < .001); however, the index of resilience was not found to differ (p = .654). This divergence between resilience and PTG may suggest that PTG postinjury is associated with the magnitude of adversity experience (e.g., Godwin et al., 2015) and that enhancing resilience and/or PTG through individualized, targeted interventions fostering positive psychology may enhance recovery for adults adjusting to TBI.

Mild traumatic brain injuries (mTBI) remain a critical area of research, particularly in understanding their mechanisms and effects on various populations. While established data collection methods such as mouthguard- and helmet-based sensors are prevalent in human studies, these techniques are not applicable in mice research due to the anatomical constraints and low mass of mouse heads. Our lab has worked in collaboration with the Neuroscience department at Western to create a novel humane mTBI mouse model which utilizes high-speeding imaging to capture video footage of impacts for subsequent analysis. Through high-speed video analysis, we derived key engineering properties but needed to ensure the accuracy of our findings. To facilitate the investigation, we utilized a dummy head surrogate equipped with a DTS 6DX PRO-A accelerometer, enabling direct comparison between sensor data and video analysis results. The dummy head, constructed at a 50-percentile scale, was positioned vertically on a raised platform and subjected to free fall from approximately 20 cm onto a cushioned testing surface, allowing for both anterior and posterior impact assessments. A total of 11 video analyses were conducted, comprising 5 anterior and 6 posterior impacts. The sensor data were analyzed over the full duration of the impact, while the video analysis focused specifically on the initial contact between the hybrid head and the floor. The analysis encompassed a total duration of 250 ms, with the impact occurring at the midpoint of this time interval. The data underwent comprehensive analysis, including comparisons between raw sensor data and various filtering techniques aimed at enhancing accuracy by mitigating noise. Preliminary results indicate that the raw rotational velocity data exhibited the lowest accuracy difference at 2.72%, while the Median and Wavelet denoising filters produced accuracy differences of 2.89% and 6.47%, respectively. These results suggest that our image-analysis approach can effectively capture head kinematics in a mouse mTBI model. Future research will focus on refining our methodology by exploring additional filtering techniques and examining a broader range of impact scenarios to further enhance data reliability and applicability.

Background: Obesity is a problem after moderate-to-severe traumatic brain injury (TBI) and associated with a myriad of chronic health problems, including cardiometabolic syndrome, chronic obstructive pulmonary disease, myocardial infarction, and type 2 diabetes. A promising evidence-based Diabetes Prevention Program Group Lifestyle Balance (GLB-TBI) intervention was specifically adapted for this population and its efficacy was shown across a randomized control trial (RCT) with 17.8 ± 41.4 lbs. of weight lost (7.9%), high participation rates (89.6%) across the 12-month program, and significant improvements in diastolic blood pressure, triglycerides, and HDL cholesterol. To expand and increase accessibility to the GLB-TBI, the efficacy of a telehealth-delivered (tGLB-TBI) is currently being tested through a national-level RCT. However, a wide range of program-related phenomena, including perceived experiences and facilitators and barriers to engagement with the tGLB-TBI remain unknown and critical to successful implementation.

Objective: The objective of this qualitative study is to extend findings from the current RCT by providing an in-depth, multi-faceted exploration of participant and coach perspectives to obtain a better understanding about the experiential outcomes in the national study and identify information required to optimize telehealth delivery of the program in the future.

Methods: We adopted an exploratory case study approach through an interpretivist paradigm, which focuses on discovering realities about the study across participants’ and coaches’ backgrounds, views, and experiences. Audio-recorded 60-90-minute focus group and individual interviews with consenting program participants and coaches (n = 2 - 6) are being conducted through Teams videoconferencing software within a month of completing the final assessment of the 12-month intervention. To-date, the first of four cohorts have been completed. Reflexive thematic analysis of the transcribed audio-recorded data is being used to analyze, and report patterns (themes) within and across participant and coach experiences in the program.

Results: To capture perceived changes/similarities across cohorts, intra-analysis themes are developed within each cohort before developing themes across cohorts. Preliminary results from reflexive thematic analyses within the first cohort will be shared. Five participants (4 male, 1 female) and the two coaches (2 female) who deliver both programs were included. Themes related to the influence of program leaders, the range of program-related benefits after TBI, and how participant identity affects engagement were generated.

Discussion: Perceptions about program experiences, engagement, and outcomes in the first cohort identified how the telehealth-delivered intervention led to meaningful activities and buy-in from all parties. Insights drawn from how themes correspond to inner mechanisms of change will be discussed, in addition to implications for future research and practice related to telehealth-delivered health-behavior programs for people with TBI.

Objectives: Fatigue is a frequently reported complaint by patients with neurological brain disorders and can be profoundly disabling. Fatigue concerns a subjective experience that often originates from multiple factors and a distinction can be made between physical fatigue and mental fatigue. Especially for patients with brain injury, it has been suggested that mental fatigue (e.g. experiencing a reduced capacity to perform mental activities) plays an important role. So far, fatigue has often been investigated as a general concept, including both mental fatigue and physical fatigue, for which elevated levels of fatigue have been reported in almost all neurological populations, including traumatic brain injury (TBI), subarachnoid haemorrhage (SAH), low-grade gliomas (LGG) and multiple scleroses (MS). However, to date, it is not clear to which extent this concerns physical fatigue or mental fatigue. The present study aims to investigate the prevalence of mental fatigue versus physical fatigue across different neurological brain disorders.

Methods: Data were obtained from observational studies and clinical records from the University Medical Center Groningen, the Netherlands. We included 45 patients with mild TBI, 25 patients with moderate-severe TBI, 54 patients with SAH, 35 patients with LGG and 61 patients with MS. Mental fatigue and physical fatigue were measured with the Dutch Multifactor Fatigue Scale.

Results: High levels of mental fatigue were reported by 78% of patients for mild TBI, 60% for moderate-severe TBI, 57% for SAH, 17% for LGG and 69% for MS. High levels of physical fatigue were reported by 56% of patients for mild TBI, 36% for moderate-severe TBI, 33% for SAH, 6% for LGG and 48% for MS. When considering the overlap between mental fatigue and physical fatigue, we found that from the patients who reported severe mental fatigue, 63% of patients also reported severe physical fatigue for mild TBI, 53% for moderate-severe TBI, 52% for SAH, 0% for LGG and 64% for MS.

Conclusions: Severe mental fatigue was reported by high percentages of patients with neurological brain disorders. Interestingly, for all groups, a larger proportion of patients reported severe mental fatigue compared to physical fatigue.

Background: After a concussion a subgroup of patients continues to experience symptoms up to several months or even years after injury, referred to as persistent post-concussion symptoms (PPCS). PPCS are associated with a substantial decrease in quality of life, loss of work productivity, and high economic costs. However, evidence-based treatment options are limited. Reduced psychological flexibility – the ability to act in alignment with values in the presence of inner discomfort such as pain and distress – is proposed to play an important role in the development and maintenance of PPCS. Acceptance and commitment therapy (ACT), a third-wave behavioural therapy that aims to improve psychological flexibility, is therefore a promising treatment option.
Objectives: The current study aimed to evaluate the effectiveness of an ACT intervention in patients with PPCS. The primary objectives were to evaluate the effect of ACT on satisfaction with daily functioning, acceptance, and value-based behaviour after treatment and at three months follow-up. The secondary objectives were to evaluate the effect of ACT on psychological distress, PPCS, and cognitive fusion.

Design: A non-concurrent multiple-baseline A-B single-case experimental design (SCED) with a randomized baseline was conducted. The baseline phase (A-phase) was 2 to 5 weeks, the treatment phase was 14 weeks, and the follow-up phase was 12 weeks (treatment+follow-up = B-phase). Repeated measurements were taken daily during baseline and weekly during treatment and follow-up, and additional measurements were taken with questionnaires at 5 different time points throughout the study.
Participants: 6 participants seeking help for PPCS and referred to the Medical Psychology department of VieCuri Medical Center participated in the study.

Outcome Variables: Primary outcomes were satisfaction with daily functioning, acceptance, and value-based behaviour. Secondary outcomes were psychological distress, post-concussion symptoms, and cognitive fusion.

Results: The repeated measures of the primary outcomes showed moderate to large improvements in satisfaction with daily functioning, moderate to very large improvements on acceptance, and small to moderate to large improvements on value-based behaviour. Assessment using questionnaires revealed reliable improvements in quality of life for five participants, in acceptance for two participants, and in value-based behaviour for two participants. All participants experienced improvements regarding secondary outcomes; psychological distress, post-concussion symptoms, and cognitive fusion, which was a reliable improvement for some participants.

Conclusions: This study offers initial evidence that ACT may be effective in treating individuals with PPCS following a concussion. The findings suggest that ACT can enhance satisfaction with daily functioning, promote greater acceptance (by reducing the struggle with symptoms), and enable individuals to engage in value-driven behaviors. Further research is needed to confirm these findings on the effectiveness of ACT for PPCS.

Most people recover spontaneously following a concussion, however, there is a subgroup of people who experience persistent post-concussion symptoms (PPCS) months or years following the concussion. PPCS are complex and vary greatly between people. Enhancing our understanding of PPCS is crucial to improve diagnostics and treatments. This effort may be limited by the methods used to assess PPCS, which often depend on retrospective memory reports, which can be susceptible to memory bias. They may not accurately reflect the day-to-day variability in PPCS, leading to an incomplete representation of symptom experiences. In order to gain more insight into the day-to-day variability we developed and studied the feasibility of an mHealth application that allows individuals to self-monitor their PPCS in real time. This study aimed to assess the strength of the relationship between the real-time experience of PPCS as measured with the new mHealth application and the commonly used retrospective Rivermead Post-Concussion Symptoms Questionnaire (RPQ).

Twenty-three individuals with PPCS self-monitored their symptoms daily for four weeks using an mHealth application. Prior to this, the participants rated which PPCS impacted them the most. Participants monitored the intensity of their symptoms once a day on a numeric 11 point scale from zero to ten. Afterwards, the participants rated their symptoms for the past 7 days retrospectively with the RPQ. Here we present preliminary analyses from 14 participants with complete data. From the primary PPCS ratings we calculated: total average, highest score, lowest score, and PPCS on the final day for both the total period as for the last eight days. Eleven participants indicated that headache was their primary symptom, two fatigue, and one light sensitivity. The preliminary analyses show that the day with the highest symptom intensity seems to correlate the highest with the RPQ score of that symptom. Furthermore, individuals with similar RPQ scores demonstrated highly different day-to-day PPCS patterns. Additional analyses, including within-person standard deviations, mean squared successive differences, and daily scores on the impact of PPCS on functionality and quality of life, will be presented at the conference.

Background and Aims: Acquired Brain Injury (ABI) often results in various physical and neurological challenges that require comprehensive rehabilitative care. Proper nutrition plays a crucial role in recovery, with timely nutrition shown to reduce complications, enhance immune function, and improve overall neurological outcomes. Emerging research emphasizes the relationship between the gut microbiome and brain function through the gut-brain axis, highlighting the importance of dietary fibers and probiotics in reducing inflammation and improving brain health. Furthermore, the whole diet approach, which advocates for balanced and diverse food intake rather than focusing on single nutrients, has been shown to support better cognitive function and overall recovery. This study aims to explore how nutritional interventions can improve cognitive function, mood, and overall rehabilitation outcomes in individuals with ABI.

Methods: This study is currently utilizing a comprehensive assessment protocol to investigate the impact of nutritional interventions on rehabilitative outcomes in 26 ABI patients. Nutritional intake is being evaluated through detailed food logs linking cognitive function, mental health, sleep patterns, weight, behavioural observations, and blood markers including: CBC, electrolytes, blood glucose, liver and kidney function tests, lipid profiles, thyroid hormones, inflammatory markers, Vitamin D, Vitamin B12, iron, and folate, which were assessed at baseline (July 2024) and will be assessed again six months later (January 2025) to identify biochemical changes related to dietary modifications.

Results: Based on current literature, our preliminary hypothesis expects that nutritional interventions in ABI patients will result in significant improvements across various rehabilitative outcomes. A balanced diet that includes a variety of nutrient-rich foods is likely to support better cognitive function, enhance mood, and improve sleep quality. Additionally, we anticipate that dietary interventions aimed at reducing oxidative stress and inflammation will accelerate overall recovery. We also expect that optimizing nutrient intake, including key vitamins, minerals, and essential fatty acids, will contribute to better physical and mental health outcomes. Improvements in gut health, facilitated by dietary fibers and probiotics, are also anticipated to positively influence brain function and emotional well-being.

Conclusion: We believe this study underscores the importance of a whole-diet approach to enhance rehabilitative outcomes in ABI patients. Nutritional interventions, particularly focusing on a balanced intake of essential nutrients, will significantly improve outcomes. Addressing dietary quality in ABI rehabilitation may not only enhance recovery but also provide protective benefits against further decline. Findings from this research, whether they confirm or challenge current expectations, will provide valuable direction for future work in developing more effective nutritional strategies. Continued research is warranted to explore the long-term effects of nutrition on ABI recovery and to develop tailored dietary guidelines for various patient subgroups.

Background: Social support is a process whereby an individual exchanges resources with another to enhance their well-being. This exchange can help support a positive recovery from a concussion by mitigating psychological and psychosocial symptoms related to the injury. However, the health benefits of social support are dependent on the recipient’s appraisal of support, which is influenced by demographic, socio-economic, and geographical factors. Youth facing barriers to positive development includes youth who may require additional supports to reach their full potential (e.g., racialized, low income). Their perspectives regarding desired social support are currently unknown and may differ from those previously described in the literature who do not experience similar life circumstances.

Purpose: The purpose of the study was to explore the experiences of youth facing barriers to positive development who have sustained a concussion to develop a detailed and rich understanding about what constitutes meaningful social support during concussion recovery.

Methods: The study used an interpretive phenomenological methodology and operated within a constructivist paradigm that adhered to a relativist ontology and a subjectivist/transactional epistemology. Four participants aged 13 to 18 years who experienced a concussion during high school and that self-identify as a youth facing barriers to positive development were recruited. Data were collected via in-person or virtual one-on-one interviews, comprising demographic and rapport building questions, a concentric circle activity, and semi-structured interview questions. Interviews were analyzed using interpretive phenomenological analysis.

Results: Through analysis, four overarching themes were co-created regarding what constitutes meaningful social support to the participants of the study during their concussion recovery. Participants of the study expressed how they valued social support that helped them preserve their independence, allowed them to retain their identity following their injury and that which made them feel less emotionally and physically isolated. They also highlighted the importance of adult figures within their recovery that provided them with dependable support that prioritized their health in occasions where they did not want to. Participants outlined how meaningful social support included that which addressed and negated the challenges they faced during the recovery from their injury. Whereas social interactions that perpetuated these challenges were understood as negative or harmful to their recovery.

Significance: This investigation provides a better understanding of participants’ experiences of receiving social support during concussion recovery. The findings of the study provide insight into aspects of meaningful social support regarding who it is delivered by and why certain forms are valued over others. Findings highlight the importance of matching provided social support following a concussion injury to the needs and wants of the individual. It also provides insight into how effective social support may be provided to individuals who experience similar life circumstances to the participants of the study.

Objective: Post-stroke driving fitness is essential for maintaining independence and quality of life, necessitating accurate assessments. With the rising demand for evaluations that reliably predict real-world driving performance, this study aimed to investigate the relationship between neuropsychological test performance and on-road driving ability in stroke patients undergoing a multidisciplinary driving assessment. Visual attention capacity—encompassing selective and divided attention—plays a pivotal role in post-stroke driving, crucial for hazard detection, traffic navigation, and quick decision-making. The study had three objectives: 1) to explore the predictive value of a standardized neuropsychological test battery on driving performance; 2) to validate the Norwegian translation of the P-Drive on-road rating protocol; and 3) to assess a novel computerized test measuring visual attention capacity within a multidisciplinary framework, emphasizing quick yet accurate testing.

Methods: Sixty-three stroke patients (50 men; mean age 59 ± 11 years) participated. Each participant completed a neuropsychological test battery. Of the fifty participants referred for an on-road driving assessment (n = 44), driving ability was evaluated using the Norwegian adaptation of the P-Drive protocol, independently scored by an occupational therapist. The neuropsychological assessments included the Sunnaas Driving Test of Visual Attention and Reaction Time (SDTVART), Mini-Mental State Examination (MMSE), Trail Making Tests A and B, WAIS-IV Coding and Digit Span, D-KEFS Color Word Interference Tests 1-3, Rey Complex Figure Test, Greek Cross 3D copy, and the Clock Drawing Test. Additionally, a computerized test measuring visual attention and reaction time (CTAR) was administered to all participants; however, CTAR results were not included in the multidisciplinary clinical decision regarding driving fitness.

Results: The linear regression model predicting on-road driving performance (P-DRIVE) explained 61% of the variance (Adjusted R² = 0.61) and was significant (F(14, 10) = 3.66, p = 0.02). The Spearman correlation between P-DRIVE and the multidisciplinary driving assessment decision (Yes/No) was r = 0.62, indicating a moderate positive association. This correlation was statistically significant (p < 0.001), based on a sample size of n = 44, supporting the strong validation of the P-Drive protocol. Passing the driving assessment correlated with better on-road driving performance rated with P-DRIVE, underscoring its relevance in predicting driving ability.

Conclusion: These findings highlight the critical role of targeted neuropsychological assessments in evaluating post-stroke driving fitness. Computerized tests designed for individuals with aphasia provide a standardized evaluation that enhance assessment accuracy. Standardized on-road tests remain the gold standard for measuring driving ability in real-world conditions, paving the way for improved patient outcomes and bolstering road safety, ensuring that stroke survivors can reclaim their independence behind the wheel with confidence.

Objective: Post-stroke driving assessments must incorporate precise and ecologically valid evaluations to ensure road safety and support survivors’ independence. In Norway, many stroke patients are predominantly assessed for driving fitness using only the Mini-Mental State Examination (MMSE), the Clock Drawing Test (CDT), and the Trail Making Tests A and B (TMT-A and TMT-B). This study aimed to investigate the relationship between performance on these screening tests and: 1) the results of an on-road driving test rated with the P-DRIVE scoring protocol, and 2) the multidisciplinary outcome of pass or fail in the driving assessment.

Methods: Forty-four stroke patients (thirty-six men, mean age 58.3 ± 12.4 years) participated in this study. Each participant completed the MMSE, TMT-A, TMT-B, and the CDT. Logistic regression analysis was performed to determine the relationship between TMT-A, TMT-B, CDT, and MMSE as independent variables and the binary outcome of the multidisciplinary driving assessment (Pass or Fail). Additionally, linear regression was utilized to predict driving performance as rated by P-DRIVE, based on the same independent variables.

Results: The logistic regression analysis indicated that the combination of neuropsychological tests significantly predicted the multidisciplinary driving assessment outcome, with TMT-A showing a negative association (Odds Ratio [OR] = 0.970) and MMSE exhibiting a positive but non-significant effect (OR = 1.230). In the linear regression model predicting P-DRIVE, an intercept of 113.82 was observed, with TMT-A significantly contributing to driving performance (β = -0.299, p = 0.014). However, TMT-B, CDT, and MMSE did not show statistically significant contributions. The model explained approximately 28.47% of the variance in P-DRIVE (Adjusted R² = 0.2005) and was statistically significant (p = 0.01963).

Conclusion: These findings underscore the critical importance of targeted neuropsychological assessments in evaluating post-stroke driving fitness. While TMT-A emerged as a significant predictor of driving performance, MMSE did not contribute meaningfully to the predictive models. This highlights the need to expand the cognitive assessment repertoire beyond the MMSE, CDT, and TMT tests to enhance the accuracy of driving fitness evaluations. Ultimately, such comprehensive assessments are essential for ensuring road safety and facilitating stroke survivors' return to independent driving.

Background: Traumatic brain injury (TBI) is prevalent among children and adolescents, with wide-ranging negative impacts on their cognitive, physical, social, family, and behavioral functioning. Extensive research has documented the adverse effects of pediatric TBI on social functioning specifically. Studies have shown that TBI can disrupt overall social competence, including reduced social participation and impaired interactions and friendships. Additionally, emerging research suggests that children and adolescents with TBI may be at higher risk for socially maladaptive or risky behaviors and may struggle with socio-moral reasoning (SMR). SMR is an important social-cognitive skill that refers to the ability to analyze and evaluate social situations in the light of moral criteria in order to make judgments about right and wrong and regulate behavior. As such, the sound development of SMR promotes the establishment of healthy social behaviors and positive interpersonal interactions, while regulating and inhibiting the emergence of socially inappropriate behaviors. It is therefore vital to be able to document and enhance young people's SMR skills in order to identify any potential difficulties and remediate social difficulties before they infringe on social relationships and quality of life. However, few assessment and intervention tools exist to quantify or qualify SMR in young people, and most existing measures are limited by poor ecological validity, outdated scenarios, and unengaging presentation modalities for contemporary tech-savvy youth, thus limiting engagement and motivation. OBJECTIVE: This study documents the co-creation design phase and content development process of an innovative technosocial tool for youth who sustain TBI, aimed at addressing SMR assessment and intervention challenges through a novel serious video game.

Design: Stages of developing a novel serious video game are described, from its theoretical grounding in neuropsychology and social neurosciences to its practical development based on multi-sectorial expertise and testing with relevant focus groups. Analysis of qualitative data from the co-creation process involving researchers, industry partners, and diverse user groups are presented through focus groups and iterative design processes to ensure the game's alignment with adolescents' interests, learning styles, and motivators. The content development phase consisted of a literature review and expert panel consultations. Results from initial testing (“game play tests”) indicate that the game shows promise as an engaging and effective tool for assessing and enhancing SMR in adolescents, with potential applications in both research and clinical settings for addressing social cognitive deficits after pediatric TBI

The Significance: To ensure a robust development process, the rationale underlying the multi-step creation and design, format choices and content development are discussed alongside their associated strengths, limitations, opportunities, and challenges and to ensure greater replicability in social cognitive task development.

Objective: To compare characteristics of patients referred for treatment of persistent postconcussion symptoms (PPCS) with those of research subjects, followed in a prospective study of mTBI, who developed PPCS.

Methods: The sample included 198 people between the ages of 18 and 60 years with PPCS, selected from two studies, including 92 from a prospective study of individuals followed from the emergency department (ED) (“prospective ED sample”), and 106 from a study of patients referred to a hospital-based rehabilitation clinic (“clinical rehabilitation sample”). The prospective ED sample included individuals presenting at the municipal ED or the university hospital in Trondheim with mTBI from April 2014 to December 2015, and a proportion of these later developed PPCS (measured at 3- or 12-months following injury). Participants in the clinical rehabilitation sample were treatment seeking persons referred to specialized health care, from September 2019 to April 2023, with postconcussion symptoms. Data from these participants were collected from the initial clinical interview 3-18 months after injury. PPCS was defined as British Columbia Post-Concussion Symptom Inventory (BC-PSI) scores ≥13 or reporting at least three moderate or severe symptoms, and/or Rivermead Postconcussion Symptom Questionnaire (RPQ) scores ≥ 12. Functional global outcome, work/school participation, resilience, and presence of fatigue were examined.

Results: Among the clinical rehabilitation sample, 43% did not meet the World Health Organization mTBI Task Force criteria and were conceptualized as having “possible mTBI.” Forty-one percent of the participants in the clinical rehabilitation sample had only seen their general practitioner, and not presented to any ED. More patients from the clinical rehabilitation sample had not returned to work/school after injury (43%) than in the prospective ED sample (18%), had a significantly higher total RPQ score (30 vs. 17, p<0.001) and significantly greater number of monthly headache days (p<0.001). Individuals from the clinical rehabilitation sample had a significantly lower GOSE score than individuals from the prospective ED sample (median score 6 vs. 7, p<0.001). There was also evidence of lower resilience among individuals in the clinical rehabilitation sample.

Conclusions: MTBI patients with PPCS from a prospective research study differ in clinically important ways from treatment seeking patients with PPCS referred for specialized health care. The treatment seeking patients have milder injuries, yet more symptoms, worse functional outcome, and lower resilience. Results from prospective studies of patients with mTBI may not be generalizable to patients seeking treatment for PPCS.

Background: Aerobic exercise testing post-concussion identifies functional deficits and facilitates exercise recommendations promoting clinical recovery. Despite its effectiveness for rehabilitation, no validated post-concussion exercise test sensitive to the functional limitations of Para-athletes currently exists.

Objectives: To develop an incremental post-concussion exercise test using arm crank ergometry [Calgary Adapted aRm Ergometer (CARE) Test] with comparable cerebrovascular and systemic physiological responses to the Calgary Concussion Cycle Test (CCCT) in able-bodied adults.

Methods: Twenty participants (age 18-51;10F,10M) completed the CARE Test and CCCT to volitional fatigue in randomized order. Middle cerebral artery velocity (MCAv), heart rate (HR), mean arterial pressure (MAP), and partial pressure of end-tidal carbon dioxide (PETCO₂) were measured throughout both tests. Mean differences were compared at baseline, 25, 50, 75 and 100 percent of test completion. Data were normalized to test duration to account for differences between tests. Intraclass correlation (ICC) and Cohen’s d effect sizes were calculated to assess agreement and reliability between tests.

Results: The mean difference in HR between the CCCT and CARE Test progressively increased with exercise intensity, ranging from 2 bpm (p = 0.45) to 8 bpm (p < 0.05) at 25% and 100% test completion respectively. Reliability for HR was moderate across all intensity levels (ICC), with effect sizes ranging from negligible to medium. MCAv mean differences increased with intensity, ranging from 1.50cm/s at 25% test completion (p = 0.45) to 5.37cm/s at 100% test completion (p < 0.05). Reliability for MCAv was good and effect sizes remained negligible to small. MAP differences between the tests remained stable, ranging from 4.05 mmHg at 25% test completion (p = 0.11) to 4.83 mmHg at 100% test completion (p = 0.076), with moderate reliability and small effect size. Mean difference in PETCO₂ increased steadily until 75% test completion (2.39 to 4.93 Torr, p < 0.05). PETCO₂ reliability was moderate to good with medium to large effect size. At 100% test completion, the PETCO₂ difference of 2.00 Torr was considered a small effect size.

Conclusions: Despite large muscle mass differences between the upper and lower body, the CARE Test represents a promising alternative to the CCCT, demonstrating moderate physiological comparability across measured variables. Importantly, MCAv displayed good reliability between tests. Impairments in MCAv regulation are associated with concussion and the development of novel exercise tests for concussion rehabilitation must consider the cerebrovascular response. Differences in HR and PETCO₂ emerged at higher intensities, suggesting a robust physiological response to high intensity exercise exists for both upper and lower body modalities. The development of the CARE Test advances concussion rehabilitation strategies with a cerebrovascular focus towards Para-athletes. Future studies will assess the CARE Test in adolescents and Para-athletes with lower-limb limitations to promote accessible clinical exercise prescription following concussion.

Context: Athletes playing contact sports are at risk of sustaining a sport-related concussion (SRC) due to the high prevalence of impacts, especially head impacts. More specifically, ice hockey players are at increased risk as it is estimated that they can sustain over 200 head impacts per season. Given the potential consequences of sustaining a SRC on athletes’ wellbeing, preventative strategies are warranted to protect their health. Avoiding impacts requires proper tracking and awareness of surroundings to allow for game analysis and obstacle detection, all of which are based on perceptual-cognitive skills. As such, it can be hypothesized that perceptual-cognitive skills may aid in the prevention of repeated head impacts in ice hockey.

Methods: University level varsity male ice hockey players, from the Université du Québec à Trois-Rivières (UQTR) Patriotes, were recruited for this study. Baseline perceptual-cognitive skills were assessed during the pre-season period (August 2023) through three-dimensional multiple-object-tracking, using a commercialised tool called NeuroTracker. For the first 8 games of the regular season (2023-24), the participants’ helmets were each fitted with CUE sport sensors to log the quantity and quality of head impacts that the participants were subjected to in game context. The number of head impacts (i.e., quantity), as well as their intensity metrics (i.e., quality) were recorded.

Results: The sample consisted of 9 participants (average age: 23.67 ± 1.58 years) with an average weight of 86.64 ± 4.99 kg. The sample’s mean NeuroTracker score was of 1.51 ± 0.26 m/s. For all participants combined, the cumulated magnitude of the sustained head impacts over 8 games averaged 581.33 ± 245.79 G and ranged from 290.00 G to 988.00 G, the cumulated number of impacts averaged 63.00 ± 20.67 impacts and ranged from 32.00 impacts to 96.00 impacts, and the cumulated HIC score averaged 149.59 ± 97.67 and ranged from 45.84 to 326.93. No significant associations were observed between the NeuroTracker scores and the three different variables of interest when analysed with Pearson correlation tests.

Conclusions: The results of this pilot study suggest that perceptual-cognitive skills did not play a role in the prevention of repeated head impacts in this sample, as no significant correlations were observed between the NeuroTracker scores and the variables of interest (i.e., number of head impacts, magnitude of impacts, and HIC scores). Results may have been affected by the small sample size and the short time frame. Since there is a great potential for clinical applications in the prevention and rehabilitation of SRC through the improvement of perceptual-cognitive skills, future study should involve a larger sample, and data should be analyzed over one full season to better understand the role of perceptual-cognitive skills on head impact prevention.

Background: Pediatric concussions have garnered attention due to their prevalence and potential long-term effects. Most research focuses on sport- and recreational-related concussions (SRRC), while other etiologies such as motor vehicle accidents (MVA) get overlooked. However, given the more physically and emotionally traumatic nature of MVA, these injuries may result in more severe outcomes and drawn -out recovery. Accordingly, this study aimed to evaluate the relative risk of developing PPCS between SRRC and MVA, as well as compare psycho-affective health, cognition, and quality of life following injury.

Methods: We retrospectively analyzed prospective data from pediatric patients (age m = 14.7 years) evaluated at a concussion clinic from 2017-2023. All participants (N = 67) were categorized based on injury mechanism (SRRC, n = 47; MVA n = 20), and no participant had a prior history of concussion. All participants came to the clinic two times, separated by approximately 1 month (eval 1, m = 16.7 days post-injury; eval 2, m = 46.3 days post-injury). Outcome measures included the Rivermead Post-Concussion Questionnaire (RPQ), Beck Depression and Anxiety Inventory (BDI, BAI), Behavior Rating Inventory of Executive Function (BRIEF), and Neurological Quality of Life (Neuro-QoL) assessments. Chi-square tests were used to evaluate relative risk, and repeated measures ANOVAs (2 group x 2 time) and t-tests (using Bonferroni correction) were used to evaluate main effects and significant interactions, respectively.

Results: MVA patients were more likely to experience loss of consciousness (OR = 7.2, p ≤ 0.01) and incur post-injury amnesia (OR = 3.3, p’s ≤ 05). Relative risk for developing PPCS was greater in the MVA than SRRC group (RR = 3.8, p = 0.01). Across both timepoints the MVA group reported greater symptom burden on the RPQ (13 & 16), reported greater emotional (RPQemotion) and cognitive (RPQcognition) disruptions, and greater sleep disturbance (p’s < 0.05). Furthermore, a group x time interaction was observed with MVA exhibiting greater levels of fatigue than SRRC at timepoint 2 (p < 0.01). No significant group differences were observed for depression, anxiety, or parent/guardian reports of executive function (p’s ≥ 0.2).

Conclusions: Adolescents with MVA-related concussions are more likely to develop PPCS and exhibit stronger and longer-lasting sleep disturbance and fatigue. Interestingly there were no group differences in terms of anxiety, depression, or cognition, highlighting the necessity of multi-domain assessments. These findings underscore the need for tailored clinical management strategies as pediatric patients with MVA and SRRC may experience distinct symptom sequalae.

Background: Repetitive blast exposure (RBE) associated with military occupational specialty has received considerable attention following media reports of significant long-term effects of RBE in the military. Recent work has shown interactions between history of blast exposure and increased risk for multiple medical comorbidities, as well as higher levels of involuntary military job loss due to medical reasons. However, given that many blast exposures do not result a traumatic brain injury (TBI), these injuries often go undetected. Clinical (e.g., cognitive) and biological markers of RBE are thus needed to aid in the identification and understanding of symptoms related to RBE. To date such measures have not yet been well-characterized. One clinical measure sensitive to cognitive changes following mild TBI, which is thought to result in a similar clinical presentation to RBE, is the Paced Auditory Serial Addition Test (PASAT). This measure brings together multiple aspects of cognition, including sustained attention, working memory, and auditory information processing speed. History of mTBI has also been associated with a greater rate of PASAT test discontinuation rates compared to controls. However, patterns of performance on the PASAT have not yet been well-characterized for those with a history of RBE. This study aims to determine whether PASAT performance (i.e., pattern of errors [omission versus commission], test discontinuation rate), is associated with RBE history in a sample of US Veterans.

Methods: Data were collected as part of a larger cross-sectional observational study examining multiple outcomes (e.g., biological, psychological, cognitive, neurobehavioral) and other key factors (e.g., Military Occupational Specialty, lifetime TBI history) in a cohort of Veterans with RBE. Cognitive measures relevant to the current study include the Test of Memory Malingering (TOMM) and PASAT. Primary outcomes for these analyses include the PASAT total score, total omission errors, total commission errors, and test discontinuation rate, and the Blast Ordnance and Occupational Exposure Measure (BOOM) for Self-Reported Lifetime Blast Exposures. Additionally, results from the TOMM will be used to exclude participants with failed performance validity. Other metrics may include scores from the Beck Anxiety Inventory (BAI), Beck Depression Inventory – 2nd Edition (BDI-II), and PTSD Checklist for DSM-5 (PCL-5).

Results: Data collection is currently underway, with 120 participants having completed the study to date. Final participants are expected to complete the protocol by the end of 2024. Data and analyses will be available to present at the meeting.

Conclusions: Results from this study will help to increase our understanding of how best to assess and characterize symptoms related to RBE in clinical settings. These results may also help set the foundation for future research, such as how to develop evidence-based treatments to address persistent clinical symptoms related to RBE.

Background: Persisting symptoms following TBI can vary across individuals, and treatment is often complicated by multiple medical and psychological comorbidities. Multidisciplinary teams composed of specialists in TBI care are among the most effective for holistically managing these complex symptoms. Within the Veteran Affairs System of Care, all combat Veterans are screened for TBI and, those with positive screens are referred to specialty providers. However, access to specialty TBI providers is often limited by factors including availability of services, locality, and disability status. Telehealth models have been proposed as a solution to many of these barriers. However, more work is needed to determine whether a telehealth model of multidisciplinary TBI care for Veterans is feasible. This project sought to determine the feasibility, acceptability, and usability of a multidisciplinary TBI telehealth clinical model at the VA Hudson Valley Healthcare System (VA HVHCS).

Methods: The VA HVHCS was awarded funding by the VA Office of Rural Health to establish a multidisciplinary telehealth TBI program aimed at addressing gaps in specialty TBI care. The VA HVHCS team consisted of three TBI providers, two speech therapists, one psychologist, and a TBI clinical coordinator. Patients were referred via interfacility consults (from other VA facilities) or internally. Patients connected with providers from their personal devices via a secure telehealth interface. Initial evaluation included history of present illness, a targeted physical exam, completion of the Neurobehavioral Symptom Inventory (NSI), and development of an individualized care plan. Each patient also completed a Patient Satisfaction Survey (PSS). Feasibility will be measured based on clinical metrics such as the number of referrals, completed consults, referrals to treatment, no-show rate, and the ease of appointment scheduling (from the PSS). Acceptability is defined here as how satisfied patients were with their treatment (based on relevant PSS questions), and usability will be based on reported satisfaction with the telehealth interface (based on relevant PSS questions).

Results: Between fiscal year (FY) 2022 and FY24, the TBI/Telehealth Clinic received 2,891 total referrals, 2,490 of which were interfacility consults, and 401 were from VA HVHCS. Data analysis related to the PSS and other feasibility metrics are currently being compiled and analyzed by our team. It is expected that these data will be available for presentation by Spring 2025.

Conclusions: This project reports on an innovative approach to TBI care that may be translated nationally across VA if found to be feasible, acceptable, and usable by patients. Translating this telehealth model nationwide would provide a crucial alternative to standard of care and fill an important gap for Veterans with limited access to specialty care.

Introduction: It is estimated that more than 50% of athletes do not report their concussion symptoms, highlighting a significant issue within the sports community. Since the diagnosis of concussions relies heavily on self-disclosure of symptoms, this practice of under-reporting exposes athletes to an increased risk of future traumatic brain injuries and post-concussion symptoms. Various factors influencing nondisclosure behavior—such as diagnosed concussion history, sex, knowledge levels, and attitudes toward concussions—have been studied, yielding mixed results. Moreover, few studies have employed qualitative methods to explore the experiences of athletes from diverse sports regarding the disclosure process. Utilizing a mixed-methods approach, this study aims to examine the reporting behaviors of university athletes, focusing on their attitudes, knowledge, sex and diagnosed concussion history, while also identifying barriers to reporting among both athletes who choose to disclose or not their concussion symptoms.

Methods: Fifty university student-athletes (32 females and 18 males) who had experienced at least one concussion symptom during a practice or competition were recruited for the study. They completed an online survey that included a modified version of the Rosenbaum Concussion Knowledge and Attitudes Survey-Student Version (RoCKAS-ST), along with open-ended questions

Results: Athletes scored high on the Concussion Knowledge Index (M = 20.7), yet the majority chose not to report their concussion symptoms (n = 39/50). Those who under-reported tended to have less favorable attitudes toward concussions, which were significantly related to their reporting behaviors. Female athletes exhibited more favorable attitudes toward concussions; however, no sex-based differences were observed for knowledge levels. Qualitative analysis revealed several key motivations for non-disclosure, including minimization of symptoms, negative repercussions, lack of agency, athletic culture, and knowledge. Additionally, some athletes cited the concussion protocol as a reason for their reluctance to disclose symptoms. In contrast, athletes who reported their symptoms had a more positive view of the reporting process compared to those who did not, stating they would all be willing to disclose their symptoms again if confronted with a similar situation.

Conclusions: A significant number of athletes did not disclose their concussion symptoms. Qualitative analysis identified several barriers to disclosure, including a negative perception of the concussion protocol, offering a novel contribution to the existing literature. On the contrary, athletes who disclosed their symptoms expressed satisfaction with the care they received and held a positive view of the concussion protocol. This implies that non-disclosing athletes may have misconceptions about the protocol, underscoring the need for educational programs to address and clarify these misunderstandings. Future studies should investigate individual factors that may predict reporting behaviors among athletes. The role of each athlete's engagement in their recovery process should also be considered.

Objectives: The current analysis compares the school services, accommodations, and supports of children with traumatic brain injury (TBI) who receive structured return-to-learn (RTL) support through BrainSTEPS compared to students who receive variable RTL supports (control arm).

Methods: This study is a secondary analysis of data from a longitudinal project that examines RTL support for students with TBI. Demographic and injury-related information was collected via caregiver report on REDCap. Specific RTL support was measured through The Child and Adolescent Scale of Participation (CASP) and caregiver-reported academic records. Descriptive statistics and an analysis of covariance (ANCOVA) investigated differences in the type of RTL services provided for students with TBI based on their study arm (BrainSTEPS or control) or injury severity (mild or moderate/severe), while controlling for time.

Results: This analysis included a total of 398 observations across 84 participants with an average of 4.74 observations per participant. The average age of students was 13.05 years old (SD = 3.44) for those who received BrainSTEPS support and 11.27 years old (SD = 3.64) for those who received variable supports (control group). In the ANCOVA results, the main effect for BrainSTEPS versus control group was significant, F(1, 392) = 13.35, p < .001, ηp² = 0.03, indicating the students who were receiving the support of BrainSTEPS were significantly more likely to report receiving formal school services. The main effect for injury severity was also significant, F(1, 392) = 20.41, p < .001, ηp² = 0.05, indicating students with more moderate/severe injuries were significantly more likely to receive supports than students with mild injuries.

Conclusions: This project is unique in its comparison of the structure of support and the types of services a student could receive in their recovery journey. The use of ANCOVA helps portray the significant differences between a structured and variable RTL program and the experiences of students recovering from a TBI. Receiving appropriate and effective services is a crucial part of the RTL process and is a gap in the current academic model.

The benefits for individuals with acquired brain injuries (ABI) being afforded early access to rehabilitation and experiencing smooth transitions from hospital to community settings have been widely established in the ABI literature. Ontario Health and the Ontario Neurotrauma Foundation (ONF) emphasize the importance of having the right care at the right time and place. ONF’s #1 standard states, every individual with an ABI should have timely, specialized interdisciplinary rehabilitation services that are initiated as soon as the condition of the person with the ABI allows.” In 2021, CONNECT Communities and Hamilton Health Sciences (HHS) began a partnership to implement a service focused on early access and smooth transition to a functionally designed rehabilitation environment. This program supported 160 people who transitioned from Hamilton Health Sciences Hospital to CONNECT Communities—Hamilton. CONNECT’s Life Redesign Model, deemed a leading practice through Accreditation Canada, focuses on meaningful community participation with an emphasis on social capital and meaningful community participation. The functioning of the 160 people was tracked from hospital discharge to their community setting. Using two standardized assessment measures (Care and Needs Scale -CANS and Mayo Portland Adaptability Scale - MPAI-4), it was possible to demonstrate that early access to a rehabilitation program that focuses on supporting people to engage in meaningful, functional activities that are embedded in everyday tasks, i.e., Life Redesign Model, yields positive outcomes. The MPAI-4 predicted that 67.5% of those who moved in would experience severe limitations. Upon move-out, only 22.9% fell in that same category. Likewise, the CANS predicted that 98.3% of the people could not be left alone for a few days, a week or more, but at move out, only 72% required that level of care. The results of this partnership demonstrated that early access to a transition rehabilitation program such as CONNECT made significantly positive changes for the people they support and their families. This presentation will share how outcomes are improved by having a smooth transition to rehabilitation that focuses on maximizing opportunities for neuroplasticity. Data related to having timely access to community-based rehabilitation and its effects on preferred move-out locations will be shared. It will also explain how the brain’s plasticity is heightened shortly after brain injury, creating an optimal opportunity to form new neural connections and reorganize pathways through rehabilitation. Evidence will also be provided on the neuropsychological advantages of an innovative functional approach to rehabilitation, which maximizes neuroplasticity by specifically targeting relevant skills most applicable to an individual’s daily life. This approach also enhanced their involvement in pursuing rehabilitation goals, increasing mood, autonomy, and motivation, all of which are key factors known to improve rehabilitation outcomes and, ultimately, help people to “just move home”.

Introduction: The Coma Recovery Scale-Revised (CRS-R) is a common data element and widely used assessment for patients with disorders of consciousness (DoC). Prior work has generated a data visualization tool, called the Recovery Ruler, to display CRS-R assessment results.

Objectives: We evaluated the reach, adoption, and implementation of the Recovery Ruler across four DoC programs in the United States. We also aimed to identify facilitators and barriers to adopting and implementing the Recovery Ruler in clinical practice.

Methods: We conducted an explanatory sequential mixed methods study. We provided Recovery Ruler education to rehabilitation practitioners at four inpatient DoC programs. Eligible practitioners had at least six months of CRS-R experience. Each practitioner was invited to participate in a study consisting of twelve weekly surveys followed by three monthly surveys. Each survey assessed the reach, adoption, and implementation of the Recovery Ruler. We used the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Framework to examine: 1) Reach: % of eligible rehabilitation practitioners who participated in the Recovery Ruler study; 2) Adoption: % of participants who reported adopting the Recovery Ruler at least once; and 3) Implementation: % of opportunities when participants reported using the Recovery Ruler with the CRS-R. Finally, we recruited participants from each DoC program to participate in a 45-minute semi-structured interview to identify the barriers and facilitators to using the Recovery Ruler. Interviews were audio-recorded, transcribed, and de-identified. We used the Theoretical Domains Framework (TDF) to conduct a deductive framework analysis of each transcript.

Results: We reached 26 (41%) of 63 eligible rehabilitation practitioners who agreed to participate in the survey study. Twenty-four of the 26 participants adopted the Recovery Ruler at least once. When participants reported administering the CRS-R, practitioners implemented the Recovery Ruler 41% (232/564) of the time. We interviewed fourteen rehabilitation practitioners. Interviewees described being motivated to use the Recovery Ruler to improve communication with family caregivers (TDF: beliefs about consequences). We learned that implementation decreased because the practitioners preferred to use the Recovery Ruler only when the family was at the bedside. Practitioners suggested the Recovery Ruler would be beneficial to integrate into the electronic health care record. Competing demands and lack of knowledge presented barriers to implementation (TDF: environmental context and resources; knowledge).

Conclusions: Adoption of the Recovery Ruler was high across programs. However, we do not know why we did not ‘reach’ 59% of eligible rehabilitation practitioners for the survey study. For the adopters, the reported implementation varied across programs and over time. Identifying barriers and facilitators may support the development of a tailored implementation strategy to improve adoption and sustained implementation across DoC programs.

Introduction: Rehabilitation practitioners often use mobility-based interventions that target impairments and limitations in the ‘body structure and function’ and ‘activity’ domains within the World Health Organization’s International Classification of Functioning and Disability (WHO-ICF) framework. However, the impact of mobility-based interventions on the WHO-ICF domain of ‘personal factors’, including changes in the individual’s features like motivation, self-acceptance, and mindfulness is lesser known. Subsequently, the primary aim of this study was to explore differences in perceived ‘personal factor’ changes among individuals with acquired brain injury (ABI) completing two mobility-based interventions: group yoga and group low-intensity exercise.

Methods: This qualitative descriptive study included participants who completed either group yoga or low-intensity exercise, twice a week for eight weeks during a pilot randomized controlled trial. Demographic data were collected from 18 of the 29 eligible participants who completed in-person interviews or focus groups. A semi-structured interview guide, informed by the WHO-ICF framework, was used during interviews to explore perceived changes in ‘personal factors.’ Interviews were audio-recorded, transcribed, and then analyzed using three approaches. First, we thematically analyzed the transcripts through inductive, open coding. Second, we completed a deductive application of codes to WHO-ICF domains and categories. Lastly, using the constant comparison technique, we analyzed the WHO-ICF categories coded for yoga participants compared to exercise participants.

Results: Eighteen participants completed interviews; 9 from yoga (Mean age= 62.0 + 15.6, Mean years-since-injury= 17.8 + 19.0, 6 females) and 9 from low-intensity exercise (Mean age= 47.6 + 22.5, Mean years-since-injury= 5.5 + 5.9, 4 females). When comparing the intervention groups, two themes related to changes in ‘personal factors’ were generated: 1) Engagement in a Group Yoga Intervention Increased Participants’ Self-Regulation as They Learned to be More Mindful and Responsive to Their Bodies’ Needs. A participant stated, “Jen [yoga instructor] has taught me to listen to my body and just listen…I have learned that listening to my body, and honoring it [means] I’m not always following the instructions.” 2) Individuals Participating in Group Low-Intensity Exercise Report Increased Motivation to Prioritize Fitness. A participant stated, “I feel like [exercise] has given me a little more motivation in my everyday life to be a little bit more active.”

Discussion: These findings suggest that group yoga and group low-intensity exercise may facilitate distinct ‘personal factor’ changes for individuals with ABI. Participants in group yoga reported improved self-regulation, while those in group exercise experienced increased motivation. Despite interventions having the same dosage, differences in setting/approach likely influenced distinct outcomes. Yoga's quiet setting and focus on the mind-body connection may have promoted self-regulation, whereas the familiar, socially engaging format of low-intensity exercise likely boosted motivation. Future research should incorporate objective measures of self-regulation and motivation to quantify these perceived ‘personal factor’ changes.

Advances in traumatic brain injury (TBI) research have greatly improved our understanding of the long-term impacts on cognitive function, decision-making, and independence. As TBI is being considered a chronic condition, there is a growing need for resources that empower individuals with TBI to manage its long-term effects. In response to this, the NYU Langone Rusk Rehabilitation Traumatic Brain Injury Model System (RRTBIMS) conducted a five-year mixed-methods study to explore how individuals with TBI navigated their condition from the time of injury to the present. Participants reflected on the causes of their injury and the barriers and facilitators they encountered in understanding and managing TBI. These insights informed the development of a comprehensive “roadmap” designed to support individuals in managing TBI as a chronic condition. The study employed the Framework Analysis method to systematically code and analyze data from semi-structured interviews, identifying recurrent themes related to the lived experience of TBI. High-frequency themes were prioritized to guide the content of educational materials. Informed by these findings, a simplified version of the Intervention Mapping (IM) framework was utilized to develop specific performance objectives and messaging for the educational toolkit.

Design: Qualitative study.

Setting: Community and referral-based outreach in urban setting.

Participants: 22 individuals with TBI (interviews); 8 feedback survey respondents.

Results: The educational toolkit produced through this study consists of 39 chapters, grouped into five key areas: TBI effects, TBI as an invisible injury, TBI and relationships, independence and living with the injury, and resource navigation. Each chapter underwent a comprehensive review process, incorporating feedback from expert stakeholders. Additionally, community stakeholders reviewed the developed content for relevance, readability, look, and feel. Among survey respondents (N=8), the majority were female (62.5%) and included individuals with TBI (50%), care partners (12.5%), and healthcare professionals (37.5%). All respondents rated the quality of the educational materials as Good or Excellent, with 62.5% reporting the resources were easy to navigate. Feedback also indicated areas for future improvement, with 57.1% of respondents identifying gaps in content related to overdose and employment concerns. During this presentation, the toolkit will be described and feedback via written and/or web-based survey will be requested to improve the relevance of the toolkit to different populations, and increase distribution to individuals with TBI.

Conclusions: This study demonstrates the efficacy of utilizing qualitative data from individuals with TBI to inform the development of educational resources that address the complexities of managing TBI as a chronic condition. By integrating qualitative data directly from TBI survivors, this roadmap offers a consumer-driven, practical resource tailored to the needs of those affected by TBI. The iterative design process ensures that these materials remain both practical and responsive to community needs, positioning them as valuable resources for ongoing TBI management.

Biopsychosocial models of (neuro)disability, such as the WHO’s ICF model, provide a useful conceptual framework for understanding how cognitive functioning such as cognitive communication can be defined through the relationships among a person’s biological, environmental, and individual factors following traumatic brain injuries (TBI). These models are especially compelling for social-legal behaviors: Not only do social-legal contexts rely heavily on cognitive communication–supported activities and define behavior through functional terms (e.g., a person’s need to “communicate effectively” with an attorney), they have structural and systemic cognitive-behavioral risk factors that exert pressure on the cognitive mechanisms that support behavioral activity and participation. Given the serious overrepresentation of neurodisabilities and conditions associated with neurodisabilities among law-involved populations, there is a need for biopsychosocial modeling of cognitive communication that can capture the predictable effects of legal contexts on human cognitive behavior.

Aim: I aimed to develop a “biopsychosociallegal” model of cognitive communication and neurodisability.

Method: I synthesized experimental findings of social-legal cognition in moderate-to-severe TBI, conceptual “neurolaw” scholarship, and professional legal experience to develop a social-legal framework of functional cognitive communication. Using the model, I illustrate how various legal conditions (e.g., adversarial orientations between two legal parties) will manifest within the functional biopsychosociallegal model.

Results: The biopsychosociallegal model defines cognitive communication around three key functional behaviors (accessing information, internalizing information, and interacting with information) and the underlying cognitive mechanisms. Analysis shows parallel top-down and bottom-up effects of the law on cognitive-communication functioning, wherein the law’s structural characteristics tax the cognitive resources that support cognitive communication (bottom-up) and wherein the law’s social-behavioral paradigms create participation dynamics that distort cognitive-communication activity (top-down). Analysis also shows the effect of biological factors (i.e., TBI), which likely influence social-legal participation through bottom-up effects on cognitive resources.

Discussion: The biopsychosociallegal model demonstrates that the law can be conceptualized in two overlapping ways: first, as a unique variable within a biopsychosocial framework whose effects on cognitive communication are negative, predictable, and structural; and second, as a biopsychosociallegal limiting event or space in which functional activity is undermined by the nature of the law itself. These interpretations raise diverging policy implications for persons with TBI (or other neurodisability-associated conditions). On the one hand, reform-based modifications to legal practices and procedures may be able to reduce or control for structural confounds; on the other, reimagination-based changes to legal systems as a whole may be needed to redefine the parameters of biopsychosociallegal cognitive communication and eliminate the possibility that the law itself manifests as a functional cognitive-communication limitation.