Background: It has been well established that sleep (and wakefulness) change in the acute stage of concussion, with an increased need for sleep which has been hypothesized to be neuroprotective. For most, sleep patterns and sleep need return to pre-injury status with resolution of concussion symptoms. However, it is also well established that at least 30% of individuals go on to experience prolonged sleep disturbances, and that the pattern of sleep for these individuals changes during the post-acute phase. Further, it has also been well established that poor sleep is associated with prolonged concussion recovery. As such, there is a need to identify and understand the factors that may influence the development of long-term sleep disturbances so that these can be targeted for prevention and early intervention.

Aims: To identify patterns of recovery and factors which may be predictive of prolonged sleep disturbance among a cohort of individuals with subacute concussion from the general population. An additional aim was to examine any sex differences in recovery.

Methods: This prospective naturalistic cohort study followed 921 adults aged 17-85 years who were diagnosed with concussion in several hospital emergency departments in Toronto, Canada, who were not admitted to hospital, and who did not have any neurological or positive imaging findings. The Sleep and Concussion Questionnaire (SCQ), Sports Concussion Assessment Tool (SCAT) and Headache Questionnaire were administered at weeks 1, 2, 4, 8, 12 and 16 post-injury.

Results: From weeks two to four post-injury, sleep patterns were observed to evolve from a need for increased sleep, for some, a return toward pre-injury sleep, and for others, to symptoms of insomnia. By week 8, those whose sleep had returned to ‘normal’ - i.e., to their pre-injury sleep routine, also had lower SCAT scores overall. However, for those whose sleep had not returned to pre-injury status, statistically significant differences by sex were observed, with females experiencing greater symptoms of insomnia (p<0.01). Additional associative factors were a history of pre-injury depression (p<0.01) and neck pain (p<0.01).

Conclusions: The pattern and time frame of sleep and sleep disturbances post-concussion varies. However, based on our findings, risk factors for the development of prolonged sleep disturbances and/or sleep disorders include female sex, neck pain and a pre-morbid history of depression. Identification and treatment of these risk factors may mitigate the development of persistent sleep disorders and prolonged concussion symptoms.

There is a growing body of literature aimed at understanding the assessment and management of chronic pain after moderate to severe traumatic brain injury (TBI). Interdisciplinary pain management is accepted as gold standard for chronic pain, but there is limited evidence to guide clinicians on how to modify general pain management strategies for people with a TBI. The Be Pain Smart – Online Education Modules (BPS-OEM) are a suite of online modules, providing evidence-based training for clinicians on pain management strategies for people with a TBI. The modules have utilised optimal adult learning principles within the design to support the learning of pain management strategies and clinical decision making aligned with the Be Pain Smart – Treatment Program (BPS-TP). The online delivery allows for maximum accessibility to facilitate the training of clinicians across metropolitan and rural/remote regions. The BPS-OEM provides training and a clinical reasoning framework to assist clinicians to improve access to and the delivery of appropriate pain management services for people with a TBI. To evaluate the feasibility and acceptability of the BPS-OEM, particularly examining clinicians’ pain beliefs, confidence and clinical practice when managing pain with people who have a TBI. The added value of additional 6 group mentoring sessions to compliment the BPS-OEM will be reviewed. A sample of allied health clinicians were recruited via advertisements through the relevant New South Wales (NSW) networks. Data was collected via an online survey with outcome measures targeting clinical practice, knowledge, confidence, pain beliefs and clinical value of the BPS-OEM. Significant improvements were found in clinician confidence and pain knowledge, and in addition, clinicians’ pain beliefs were changed to align with interdisciplinary pain management approaches. The high enrolment numbers to modules and attendance to the webinars indicates that the program is feasible and accepted amongst health care professionals. In conclusion, chronic pain management following TBI is currently limited due to a lack of guidelines, knowledge, skills and confidence of clinicians. Education of clinicians about chronic pain management is a foundational step in implementing effective chronic pain management for TBI. The BPS-OEM was found to be a feasible and acceptable training method for clinicians which showed improvement in clinician knowledge, skills and confidence in chronic pain management concepts and strategies. Further research is needed to assess the effectiveness, barriers and facilitators in implementation of chronic pain management for the TBI population.

Chronic pain is a recognised consequence of moderate-to-severe traumatic brain injury (TBI), which can significantly impact rehabilitation, social participation, activities of daily living and meaningful engagement with family, peers, education, and employment. The prevalence rate is estimated between 30-50% of the TBI population, which represents a higher prevalence rate than the general community (~20%). Overall, the literature suggests the use of a biopsychosocial approach, however, there is very limited evidence to direct clinicians to select the most appropriate pain management strategies for use in this population. In response to this identified clinical gap, the Be Pain Smart – Treatment Program (BPS-TP) was developed as an interdisciplinary, patient-centred approach to pain management. The BPS-TP includes a six step online interactive clinical reasoning tool to assist clinicians to develop a personalised pain management plan for individuals with a TBI. Clinicians implement the plan using evidence-based, non-pharmacological pain management strategies specifically designed for people with cognitive impairments. The strategies are accessible on the Chronic Pain and Brain Injury Website (https://aci.health.nsw.gov.au/chronic-pain/brain-injury), which is a resource platform for people with a TBI, to use simple tools to learn to manage pain. The resources include 13 educational videos on chronic pain management topics that can be viewed by consumers and/or carers including personal stories of people with TBI managing chronic pain. The 37 strategies and 88 downloadable, printable and editable pdfs map to the seven main domains (physical function, ability to participate in social roles and activities, anxiety, depression, fatigue, sleep disturbance and pain interference) of the Patient Reported Outcome Measurement Information System – 29 (PROMIS-29+) allowing for an integrated assessment and treatment approach. The clinical effectiveness of the BPS-TP is being evaluated using a series of Single Case Experimental Designs (SCEDs). Emerging data from selected case studies in this SCED series will be presented to highlight how to use the BPS-TP and website resources to develop and implement an individually tailored pain management plan for individuals with a TBI. Pre and post scores on the PROMIS-29+ and the Brief Pain Inventory (BPI) demonstrated clinically meaningful changes in pain interference. Consequently, these preliminary results provide promising evidence for the effectiveness of the BPS-TP in reducing the level of pain interference in the lives of TBI participants which lead to additional improvements in other domains, emphasising the critical role of an interdisciplinary, patient-centred approach to pain management in this highly complex cohort.

Evidence indicates over 50% of individuals with moderate to severe traumatic brain injury (TBI) experience chronic pain that may impact physical and cognitive function and quality of life. The complex relationship that exists between cognition and pain in adults with TBI requires nuanced treatment and interventions. The objective of this study was to investigate the associations between current chronic pain, including pain intensity and interference, and cognition and current chronic head pain and cognition in individuals with moderate to severe TBI. The study was a secondary analysis of a project entitled “The Characterization and Treatment of Chronic Pain after Moderate to Severe Traumatic Brain Injury” (CPS), which was a multi-center, cross-sectional observational cohort study. Individuals were enrolled from the Traumatic Brain Injury Model Systems (TBIMS) longitudinal study, and were eligible if they independently completed one of the routine follow up interviews at years 1, 2, 5, and every 5 years thereafter in English. The final sample included 1762 participants who endorsed experiencing current chronic pain and who completed the Current Chronic Pain survey. The primary outcome measure used was the Brief Test of Adult Cognition by Telephone (BTACT) to assess cognition at the time of follow up, and measures for pain characteristics included the Brief Pain Inventory (BPI) and the Headache Impact Test (HIT-6). Results showed that individuals with TBI who reported current chronic pain exhibited lower cognitive performance compared to those who reported no pain. Among individuals who reported pain, greater pain intensity and pain interference were negatively associated with cognition, resulting in poorer cognitive performance. The BTACT scores decreased between 0.10 and 0.14 standard deviations for every one-point increase in pain intensity, and between 0.07 and 0.10 standard deviations for every one-point increase in pain interference. The negative association was even greater for individuals acknowledging chronic head pain compared to pain from other body locations. For every one-point increase on the HIT-6, BTACT scores decreased by 0.02 standard deviations. In conclusion, the negative association between current chronic pain and cognition for adults with TBI indicates the need to consider pain intensity and pain interference as factors possibly influencing cognitive ability. The findings suggest that pain management should be clinically addressed as a part of cognitive rehabilitation after TBI.

Rugby league is a collision sport that carries risk for concussions and repetitive head impacts. Some studies of former elite and professional athletes who participated in contact and collision sports reveal higher levels of chronic pain than that of the general population. The purpose of this study was to examine the association between life interference due to chronic pain and perceived cognitive decline in former elite and professional rugby league players from Australia. Former elite-level rugby league players (N=229, Age: [mean] M=52.66, [standard deviation] SD=13.46, Range=29-89) completed the Brief Pain Inventory, the Informant Questionnaire on Cognitive Decline in Elderly (IQCODE, self-report version), and the Depression, Anxiety and Stress Scale (DASS-21). Their median total years of participation playing rugby league was 23 (interquartile range [IQR]=20-27), and their median years of participation at the elite or professional level was 9 (IQR=5-12). Their mean pain interference score was 1.86 (SD=2.26, IQR=0-3.14). There were small significant positive correlations between life interference due to pain and depression (r=.28), anxiety (r=.31), stress (r=.32), and perceived cognitive decline (r=.23). The sample was divided into two groups based on their score on the Brief Pain Inventory (i.e., highest 25% vs. lower 75% of sample). Those in the high pain interference group were significantly more likely than to report a past history of depression (45.5% vs. 23.7%, [odds ratio] OR=2.68, 95% [confidence interval] CI=1.42-5.07) than those in the typical pain interference group. Those in the high pain interference group reported significantly greater symptoms of depression (Hedges’ g=0.86), anxiety (g=0.77), and stress (g=0.73), with medium-large effect sizes. They also reported significantly worse perceived cognitive functioning (g=-.051), with a medium effect size. Those in the high pain interference group were significantly more likely than those in the typical pain interference group to be experiencing moderate or greater depression, anxiety, and/or stress (48.1% vs. 23.7%, OR=2.99, 95% CI=1.56-5.72), and they were significantly more likely than those in the typical pain interference group to report cognitive decline, as measured by the IQCODE cutoff score of 3.38 (48.1% vs. 21.0%, OR=3.49, 95% CI=1.81-6.75). Some former elite and professional rugby league players report considerable life interference due to chronic pain. Those with life interference due to chronic pain also experience greater depression, anxiety, and stress, and they are more likely to report a decline in cognitive functioning.

Individuals living with the negative health consequences of a mild traumatic brain injury (mTBI) are at risk of developing poor lifestyle habits, such as low physical activity (PA), increased sedentary behaviors (SB), and poor sleep quality. Currently, research and recommendations for individuals with a TBI address sleep, sedentary time, and physical activity as separate behaviors. However, this siloed approach to treatment and research fails to capture the mutually-exclusive nature of the behaviors within a 24-hour period. Thus, this study aimed to investigate the dynamic interplay of these behaviors by assessing their frequency and distribution during 24-hour cycles in individuals with mTBI. Objective accelerometry was employed to determine if time reallocation from one behavior to another, interdaily stability (IS), and intradaily variability (IV), were associated with cognitive function and symptom severity. IS quantifies the consistency of activity patterns from one day to the next, whereas IV quantifies the degree of activity fragmentation within 24-hour cycles. Participants (n=24) were 18-55 years of age (29.81 ± 11.39), experienced a mTBI inducing injury within the year and were physician-diagnosed Participants wore an Actigraph GT3X for seven consecutive days, completed a symptom checklist (10.45 ± 13.75), and the Trail Making Test (TMT) (48.73 ± 24.04). Compositional data analysis was used to assess time allocation of four behaviors, sleep (367.14 ± 57.62), SB (688.34 ± 99.50), light PA (LPA) (201.34 ± 57.08), and moderate to vigorous PA (MVPA) (96.04 ± 41.12). IV (0.47 ± 0.25) and IS (0.80 ± 0.12) were calculated using ggir in R. Results revealed that reallocating 20 minutes into LPA from an equal amount of all other behaviors was significantly associated with faster TMT B by five seconds (β= -39.22, p=0.05). Moreover, reallocating 20 minutes from MVPA into LPA was associated with a 9 second decrease in TMT B (β=-42.06, p=0.05). Additionally, the same pattern exists with symptoms. β= -55.97, p=0.02). Relocating 20 minutes from MVPA to LPA was associated with a 12-point decrease on the symptom scale (β=-62.97, p=0.01). Moreover, results showed that those with higher IV had higher TMT B scores (β= 42.54, p=0.02). However, there was no relationship between IS and TMT B or symptoms. These results highlight the importance of considering overall activity patterns in TBI recovery and emphasize the need for further research on 24-hour activity cycles within this population.

Introduction: The neurocognitive outcomes of pediatric brain tumor survivors (PBTS) have been extensively studied but the prevalence of mental disorders, behavioral & emotional difficulties remained unclear. Furthermore, limited studies have been conducted on factors that are associated with the mental health outcomes of PBTS.

Methods: A retrospective cohort study of PBTS diagnosed between 2005 and 2020 was conducted using the clinical data extracted from the Clinical Management System of the public hospitals in Hong Kong. Parents of PBTS were invited to complete an online survey on family demographics, the psychosocial wellbeing of PBTS, lifestyle habits and parental stress.

Results: The clinical data of 274 PBTS age 0 to <24 years were included. 29/ 274 patients (10.58%) had ADHD, 19/274 patients (6.93%) had ASD, and 12/274 patients (4.38%) were diagnosed with intellectual disability (ID), indicating a higher prevalence of mental disorders in the PBTS cohort compared with the general population. An overlapping diagnostic outcome of mental disorders was also found in the cohort. Epileptic seizure was associated with the risk of intellectual disability(p<0.001). Logistic regression demonstrated that patients receiving chemotherapy or radiotherapy were susceptible to emotional problems (OR = 3.22, p=0.015 for chemotherapy; OR = 2.84, p=0.021 for RT). Emotional/ behavioural problems were associated with longer follow-up time (OR = 7.87, p=0.005). A total of 74 parents of PBTS completed the online survey. The mean age of PBTS was 13.18 years, SD= 6.16 years with 42.1% female. Better sleep quality was associated with fewer emotional and behavioral problems (r = -.34, p = .004) and reduced ADHD symptoms (r = - .42, p < .001), after adjusting for age and socioeconomic status. Additionally, longer sleep duration correlated with fewer emotional and behavioral issues (r = -.25, p = .038) and reduced autistic features (r = -.36, p < .001), after accounting for age and socioeconomic status.

Conclusions: Paediatric brain tumour survivors are at risk of mental disorders. Better sleep quality and longer sleep duration were associated with fewer emotional and behavioral difficulties.