Background: Early rehabilitation is necessary for people with traumatic brain injuries (TBI) to recover, yet 77-88% of people with TBI ever receive rehabilitation. People with TBI who are Hispanic, those without insurance, public insurance, or transportation challenges are even less likely than others to receive rehabilitation. Due to its potential to be mobile and low cost, Virtual reality (VR) is recommended as a rehabilitation option that addresses these challenges. Immersive, interactive VR has improved outcomes for people with TBI including memory and eye tracking.
Methods: This community-based participatory research project included focus groups with people with TBI (N = 12) to design virtual reality scenarios to address common rehabilitative needs. Prospective memory and eye tracking were described as the most common challenges. The authors then developed and assessed the rehabilitative effects of two new virtual reality scenarios using a HTC Vive headset on prospective memory and eye tracking among people with brain injuries (N = 11) randomized to intervention and control groups. The intervention group (n = 6) participated in the 12-minute memory scenario twice a week for 6 weeks. The control group (n = 5) participated in a memory card game for 20 minutes twice a week for 6 weeks and then participated in the memory VR scenario twice a week for 6 weeks. Four participants received 12 sessions of the 6-minute eye tracking scenario.
Results: On an objective memory test, participants in the VR intervention group (66%) improved their memory more often than the memory card control group (0%) after about 12 sessions each. On a PMRQ memory scale, the intervention and control group did not have statistically significant different mean scores after six weeks. Three out of four (75%) of participants improved their eye tracking ability after they completed the eye tracking VR scenario.
Implications: An efficacy study of the two new VR scenarios will be conducted next. Future research should assess the appropriateness of VR for different types of brain injury and co-occurring conditions.

I arrange ski trips for adults and children, safaris in Africa, surfing in the UK, and camping in Europe. We have captured in pictures on our poster our clients in different environments and facing new challenges, and we have feedback from our clients confirming the benefit they and their families obtain from these experiences. The group holidays increase their confidence and self-esteem, and clients have discussed with me that they gained an insight into their own conditions from the experience and how ‘It was the first time I felt normal’ and, ‘I realised that I could function in a group and enjoy myself’ and are part of the story of how they progressed.

We saw physiotherapy benefits from surfing in the UK and in Africa. We took a brain-damaged, ventilated client skiing in France, showing there are no physical boundaries. We facilitate children’s trips that show us the value of activities with siblings e.g. a child going down an advanced run in contrast to the rest of the family, who are on basic runs! These trips demonstrate that such activities benefit both family and carers.

It is not necessary to go overseas for some clients: similar benefits can be obtained from a surfing holiday in Devon, UK. The safari was a very positive experience, ranging from snorkeling and shark cage diving, to surfing. We saw animals from an accessible open-top vehicle and hippos from a boat, and took a group to a special-needs orphanage, and they raised money for the children and we then took the children to the beach for what was their first outing. It became difficult to tell who were clients, guides, support workers, or family.

Concussion is a significant public health concern due to the underestimated frequency of the injury and in some cases, the potential for prolonged disability. In recent years, there has been a shift to participatory-action research models in health research whereby individuals with the disease or injury of interest are directly involved in the research itself. Employing a participatory-action research model on a local level can provide important feedback and guidance to research teams to help shape future research and care. This project employs a participatory-action research model to understand patient, caregiver, and physician experiences, and to determine stakeholder-informed research objectives that can be investigated in an acute concussion clinic. This study uses a modified Delphi approach. Semi-structured interviews have been conducted with individuals with concussion (or who have recently recovered from their concussion), their caregivers/family, and clinic physicians. All participants were 18 years of age or older and recruited from an acute concussion clinic in Toronto, Canada. Interviews were audio-recorded and transcribed, and transcripts were analyzed qualitatively and sorted into themes. To ensure that the patient perspective is continuously kept at the forefront of this work, an advisory committee of past patients has been recruited to help inform the: 1) research study design; 2) interview questions; 3) interpretation of the results; and 4) ways in which results should be disseminated. 11 participants have completed a semi-structured interview to date (n=5 individuals with concussion, n=3 caregivers, n=3 clinic physicians). An additional 9 participants will be recruited and full results will be shared at the conference. After an interim qualitative analysis of the interview transcripts, the following themes were defined (in consultation with the advisory committee): concussion symptoms (i.e., direct experience with headache, cognitive difficulties), subjective experience with symptoms (i.e., being overwhelmed by concussion symptoms, frustration with fluctuating symptoms), caregiver experience (i.e., feelings of helplessness, providing household support), facilitators of recovery (i.e., normalizing recovery experience, value of early intervention), return to activities (i.e., modified work duties, supportive work environment), and challenges with providing/receiving care (i.e., financial burden of treatment, compliance with recommendations). These interviews have provided unique perspectives on the barriers, facilitators, and experiences of individuals with concussion, their caregivers/families, and clinic physicians in the context of an acute concussion clinic. The next steps consist of collaborating with the advisory committee to interpret interview themes into research objectives which will be ranked by a second group of participants to create stakeholder-informed research priorities that can be investigated in the future.

Background & aims: Depression in the context of moderate-to-severe TBI (msTBI) is highly prevalent, but its neural underpinnings are little understood. This pilot study focused on this gap through exploring voxel-wise associations between depressive symptoms and anterior prefrontal cortex (aPFC) resting-state functional connectivity (rsFC).
Methods: In a secondary analysis, BOLD fMRI resting-state scans and Personality Assessment Inventory Depression scale (PAI-DEP) scores were acquired from the Toronto Rehab TBI Recovery Study database. We examined n=32 patients with chronic msTBI and n=17 age and education-matched healthy controls. Patients with TBI were operationally grouped as Depressed (n = 13) with PAI-DEP scores ≥ 60 or as Nondepressed (n = 19) with T-scores < 60. To compare bilateral aPFC rsFC across our three study groups, we performed F-tests through seed-based connectivity analyses, while controlling for age and education. Nonparametric permutation testing was performed with threshold-free cluster enhancement (TFCE) and family-wise error (FWE) correction to identify significant group differences.

Results: Although there were no significant differences in the rsFC of the right aPFC, the left aPFC demonstrated significantly increased rsFC with the bilateral fusiform gyri, right superior temporal lobe, and right precentral gyrus (TFCE-corrected pFWE < 0.05) in the group with comorbid TBI and depression as compared to the healthy control group.

Conclusions: This preliminary study adds to limited literature that implicates the aPFC in the pathophysiology of depressive symptoms occurring in chronic msTBI. Increased rsFC between the aPFC and these four sensory and motor regions could be a clue signifying vulnerability to depression post-TBI, offering testable hypotheses for future research.

INTRODUCTION: While blood transfusions can be lifesaving, they also carry risks including thromboembolic events. This is due to multiple factors including increased blood viscosity, inflammatory response to transfused blood, and changes in the coagulation cascade. Traumatic brain injury (TBI) exhibits a unique coagulopathy, which may predispose patients to both bleeding and clotting complications. Transfusing TBI patients may add an additional layer of complexity to their coagulation profile. Therefore, this study aimed to investigate the relationship between trauma patients with TBI who receive packed red blood cell (pRBC) transfusions and the incidence of venous thromboembolism (VTE) hypothesizing that transfusion of pRBC during the initial resuscitation increases the risk of VTE.

METHODS: The Trauma Quality Improvement Program (TQIP) was queried from 2017-2021 to identify adult (>18 years-old) patients with TBI. Patients receiving pRBC transfusions were compared to those who did not receive pRBC transfusions within 4 hours of presentation. Patients that died or were discharged within 48-hours, and all transferred patients were excluded. Outcomes were compared using bivariate analyses and a multivariable logistic regression analysis to identify predictors of VTE while controlling for age, sex, obesity, vitals on arrival, surgical intervention and fractures to the pelvis, spine, and lower extremities.

RESULTS: Of 422,831 TBI patients, 28,230 (6.7%) received pRBC transfusion. Patients who were transfused were younger (median: 45 vs 61 years old, p< 0.001), but had increased injury severity score ≥ 25 (72.5% vs 20.6%, p< 0.001) and a higher rate of emergent operations (39.4% vs 6.7%, p< 0.001). Transfused patients had higher rates of pelvic fractures (29% vs 4.4%, p< 0.001), spine fractures (50.8% vs 15.7%, p< 0.001), and lower extremity fractures (37% vs 8.6%, p< 0.001). Thrombotic events were more frequently observed in pRBC transfused patients, including cerebrovascular accident (2.7% vs 0.6%, p< 0.001), and VTE (8.1% vs 1.5%, p< 0.001) comprised of deep vein thrombosis (6.4% vs 1.2%, p< 0.001), and pulmonary embolism (2.4% vs 0.4%, p< 0.001). Multivariable regression analysis found undergoing any surgery (OR = 4.78, p<0.001) followed by transfusion of pRBC within 4 hours of presentation (OR = 1.438, p < 0.001) as the strongest predictors of VTE. Additional associated risk factors were ISS ≥ 25 (OR = 1.797, p< 0.001) and male sex (OR = 1.46, p< 0.001).

CONCLUSION: Trauma patients with TBI undergoing pRBC transfusion within 4 hours of arrival had an over 40% increased associated risk of VTE, compared to patients not undergoing transfusion. Providers should be vigilant in assessing the need for transfusions in TBI patients, balancing acute TBI management with thrombotic risks. Increased provider awareness of these findings may foster better patient outcomes by avoiding unnecessary transfusions in this high-risk population.

BACKGROUND: Domestic violence (DV/IPV) is a pressing global issue, affecting 25% of women and 10% of men. In the US alone, 58 million men and women experience DV/IPV within their lifetime. The most common physical assault in DV/IPV events is injury to the head and neck, occurring in 50-80% of altercations. However, there is currently no standardized or routine evaluation of TBI in DV/IPV situations. Debilitating physical, behavioral, and cognitive symptoms can result from such injuries, interfering with the ability to perform daily tasks and increasing the long-term risk of Parkinson’s, Dementia and Chronic Traumatic Encephalopathy (CTE). The purpose of this meta-analysis is to evaluate the prevalence of TBI secondary to DV/IPV.

METHODS: A Pubmed search from September 2014, the publication date of neurosurgical concussion guidelines used for sports, to September 2022 was conducted using keywords domestic violence and/or intimate partner violence in conjunction with concussion, traumatic brain injury, and/or head injury. The resulting primary research articles were then selected based on the following inclusion criteria: participants were ≥ 18 years old, participants had experienced violence by an intimate partner, the screening tool included questions about signs and symptoms of TBI as well as an experience that could cause a TBI, and a TBI diagnosis was not required for inclusion in the study. Data collection was then performed. Inter-reviewer validation and risk of bias assessment were conducted to ensure validity of data collection.

RESULTS: Of the 8,218 publications on domestic and/or intimate partner violence, only 46 (0.6%) included keywords concussion, traumatic brain injury, or head injury. Of those 46, 11 papers were included in this meta-analysis. From these 11 papers, the meta-analysis had a total sample size of 1,498. The prevalence of IPV-related TBI within this aggregated sample was 56.1% (n=841). Two studies with a total of 119 subjects included questions to evaluate the prevalence of multiple TBIs. In this subset, the prevalence of multiple TBIs was 50.4% (n=60). To assess for TBI prevalence, three papers utilized the Brain Injury Severity assessment (BISA), two studies used the HELPS tool, three performed a semi-structured interview, two utilized a modified VA TBI screening tool, and one used a modified Miller Abuse Physical Symptoms and Injury Scale (MAPSAIS).

CONCLUSION: There is a paucity of research into TBI within the DV/IPV population as well as a lack of standardized screening and evaluation. This meta-analysis suggests that more than half of people experiencing DV/IPV have sustained one or more brain injuries. Based on concussion research in sports, prospective studies are needed to optimize the screening, evaluation, and care of concussion and TBI within the DV/IPV population.

Introduction: Therapeutic interventions for disorders of consciousness (DoC) lack consistency; evidence supports non-invasive brain stimulation, but few studies assess neuromodulation in acute-to-subacute brain-injured patients. Interventions targeting the latter phase of DoC following a severe brain injury (i.e., severe traumatic brain injury (sTBI) or global hypoxic-ischemic encephalopathy (HIE)) may be critical to promote consciousness and long-term functional recovery. This study aims to validate the feasibility and assesses the effect of a multi-sessions transcranial Alternating Current Stimulation (tACS) intervention in brain-injured patients on recovery of consciousness, related brain oscillations and brain network dynamics.

Methods: This study was conducted in twelve medically stable brain-injured adult patients (sTBI and HIE), with a Glasgow Coma Scale score ≤ 12 after continuous sedation withdrawal. Recruitment took place at the intensive care unit (ICU) of a Level 1 Trauma Center in Montreal, Quebec, Canada. The intervention included a 20-minute 10-Hz tACS at 1 mA intensity or a sham session over parieto-occipital cortical sites, repeated over 5 consecutive days. The stimulation frequency targeted alpha brain oscillations (8-13 Hz), known to be associated with consciousness. Resting-state electroencephalogram (EEG) was recorded according to the intervention’s administration: pre- and post-intervention, at 60 and 120 minutes post-intervention. Two additional recordings were included: 24 hours and one week post protocol. Multimodal measures [blood samples, pupillometry, behavioral consciousness assessments (Coma Recovery Scale-revised), actigraphy measures] were acquired from baseline up to one week after the stimulation. EEG signal analyses focused on the alpha bandwidth (8-13 Hz) using spectral and functional network analyses. Phone assessments were conducted at 3, 6 and 12 months post-tACS to measure long-term functional recovery, quality of life, and caregivers’ burden.

Results: Results demonstrate the feasibility of a 5-day tACS protocol on subacute brain-injured patients in the ICU, as well as multimodal and long-term measurements without interfering with the care team and while preserving constant relatives’/caregivers' adherence to longitudinal follow-up sessions up to 12 months post-injury. Functional connectivity measures, such as the weighted phase lag index and the directed phase lag index, along with network hubs and power topography (i.e., topographic network properties) in the alpha bandwidth, were shown effective in detecting changes throughout the repeated protocol. Brain activity changes are also reflected by behavioral improvements according to CRS-R assessments.

Conclusions: These initial results support the expansion of this study to a clinical trial including a sham stimulation to assess the efficacy of a repetitive tACS protocol on the modulation of alpha band activity, as well as recovery of signs of consciousness. This experimental design includes repeated, rigorous multimodal assessments to allow the optimal capture of subtle changes in consciousness recovery status. Finally, such a protocol may allow the identification of conditional endotypes of responders to develop a targeted intervention.

BACKGROUND: Blast trauma is unique because of its complex mechanism of injury to the brain and other vital organs due to over pressure air and bleeding from internal organs. Severe loss of blood leading to hemorrhagic shock (HS) results in inadequate supply of oxygen and fuel to the cells for the generation of ATP from the mitochondria for the cell survival. Mitochondria generate ATP for cell survival through the orchestrated action of its electron transport chain enzyme’s activities, mainly through complex I-IV and mitochondrial gatekeeper enzyme” pyruvate dehydrogenase complex. Any damage to these enzymes results in increased oxidative damage to the cells, organ’s dysfunctions and neurological disorders. Although clinical symptoms of metabolic disruption are evident soon after the injury, but actual damage mechanisms at the molecular, cellular and organ system level persists for days to years post injury.

OBJECTIVES: 1) utilize our rapid blood -based dipstick test to monitor the severity of mitochondrial electron transport chain damage in response to blast exposure and HS, and 2) develop mitochondrial targeted therapeutic strategies.

METHOD: Pre-clinical and military relevant rat model with blast exposure accompanied with or without HS and resuscitation was used. The animals underwent three repeated blast injuries of 20PSI at 15 minutes interval. After circulatory variables (MAP and pulse rate) were determined, controlled hemorrhage was induced. Rats were then bled over a 15-minute period to a MAP of 40 mmHg. Blood was collected in pre-heparinized tubes. MAP was sustained at 40 mmHg for 40 minutes by withdrawal or infusion of shed blood. Resuscitation (T60-120) followed by Blood Transfusion (T120-150). After the HS, animals were infused with either hypertonic sodium pyruvate (2M) or osmolality and volume matched control hypertonic saline. Blood collected at T0 (baseline), T60 (after injury), and T180 (end) was analyzed for plasma mitochondrial electron transport enzymes complex I, IV and pyruvate dehydrogenase by our published dipstick test.

RESULTS: Compared with baseline values, a significant decreased activity of complex I, IV and Pyruvate Dehydrogenase Complex (PDH) was noted after blast and HS in all of the animal groups. The animals also had a significantly elevated plasma lactate concentration. Although pyruvate treatment was effective in preventing the loss of these mitochondrial ETC enzyme activities, and also corrected the hyperlactatemia at the end, but it was unable to restore them to the baseline levels, suggesting the need for a combined therapeutic strategy targeted at preventing the mitochondrial damage, inflammatory cascade, antioxidant and cell death mechanisms.

CONCLUSIONS: Serial monitoring and optimization of blood complex I, IV and PDH activity could aid in prognostication and potentially guide in using mitochondrial targeted therapies to reduce the mortality from the severity of combined traumatic injuries associated with hemorrhagic shock.

BACKGROUND: Rehabilitation for patients after severe acute brain injury (SABI) and subsequent disorders of consciousness (DOC) is a complex balance of restorative strategies and medical management. There is an emerging body of evidence supporting early mobilization and rehabilitation in the acute and subacute phases of rehabilitation after SABI, including the implementation of progressive upright mobilization to support arousal, attention, and hemodynamic stability. 1, 2 Further, new evidence suggests transcutaneous auricular vagus nerve stimulation (taVNS) as a potentially effective, non-invasive neuromodulatory therapy for patients with (DOC) in both acute and chronic stages. 3, 4, 5 Little is known, however, about the safety and feasibility of paired upright mobilization and taVNS interventions in the rehabilitation of patients with chronic DOC. This work reports on the safety and feasibility of robotic enabled upright mobilization with paired taVNS for a patient with chronic DOC following SABI.

METHODS: Patient is a 50 year old male with no significant past medical history prior to diagnosis of SARS- CoV2 infection in June of 2022. Following recovery from acute respiratory symptoms, the patient began to experience new onset fatigue and shortness of breath. Medical examination identified pulmonary emboli. The patient was treated with surgical thrombectomy where he suffered an intraoperative myocardial infarct. He was subsequently diagnosed with a SABI and remains in a minimally conscious state to date. He was seen at the Abilities Research Center Advanced Technology Rehabilitation Program where he underwent 6 weeks of advanced technology physical therapy. Interventions included 2 sessions per week of progressive upright mobilization with robotic assisted-stepping using Erigo (HOCOMA) and paired taVNS (PARASYM). The first 5 weeks consisted of mobilization with Erigo alone, with the addition of paired taVNS during the 6th week. Safety and feasibility were assessed using adverse event reporting. Clinical outcomes were assessed using the Coma Recovery Scale-Revised (CRS-R) and Glasgow Coma Scale (GCS) at baseline and 4 weeks.

RESULTS: The patient participated in 6 weeks of progressive verticalization with the addition of taVNS during the 6th week. No adverse events were reported. The patient tolerated an average of 32.36 (+/-12.14) minutes time on task. The patient tolerated an average tilt angle of 42.75 (+/- 26.66) degrees with a maximum tilt of 74 degrees. At baseline the patient scored 7/15 on GCS and 8/23 on CRS-R. At 4 week reassessment, GCS increased to 9/15. Overall CRS-R score remained 8/23 however motor function subscale score increased and arousal subscale decreased, each by 1 point respectively.

CONCLUSION: These findings suggest that robotic enabled mobilization with paired taVNS, is a feasible and safe intervention for persons with chronic DOC. Future work will continue to investigate short and long term feasibility, safety, and efficacy of the intervention in patients with chronic DOC.

BACKGROUND: Risk for traumatic brain injury (TBI) within both the Veteran population and among individuals with a history of criminal justice involvement is notably high. Despite this, research examining TBI among Veterans with a history of criminal justice involvement (i.e., justice-involved Veterans) remains limited. Such a gap is disconcerting as the sequelae of TBI can impact justice-involved Veterans' engagement in Department of Veterans Affairs (VA) justice-related services (i.e., Veterans Justice Outreach and Health Care for Re-entry Veterans), thus potentially increasing risk for recidivism and impacting post-release rehabilitation and psychosocial functioning. As such, further understanding of TBI risk among justice-involved Veterans is an integral first step to informing the potential need for tailored screening and interventional efforts within VA justice-related service settings. Given this, the current project sought to better understand relative risk for TBI diagnosis among male and female Veteran recipients and non-recipients of VA justice-related services.

DATA SOURCE: Data were gathered from electronic medical record data for Veterans accessing VA services from 2005 to 2018. SAMPLE: 1,517,447 (12.48% justice-involved) male and 126 237 (8.89% justice-involved) female Veterans were included in the current cohort.

STUDY DESIGN: The current project was a cross-sectional examination of national VA electronic medical record data. Sex-stratified analyses were conducted to examine relative risk of TBI diagnosis based on use of VA justice-related services. MEASURES: Documented TBI diagnosis was the outcome of interest (as determined by ICD-9 and ICD-10 codes). Covariates included for adjusted models included: VA service use, age, race, and ethnicity.

RESULTS: Both male and female Veterans accessing VA justice-related services were more likely to have a documented TBI diagnosis in their electronic VA medical record. Associations were attenuated, yet maintained significance, in all adjusted models.

CONCLUSIONS: Given relative risk for TBI, enhancing and tailoring care for justice-involved Veterans may be critical to facilitating rehabilitation and reducing recidivism. It is likely that military (e.g., combat exposure) and non-military (e.g., physical assault in prison; childhood abuse) likely contributed to notably high rates of TBI among this population. Examination of existing services within justice-related settings and methods of augmenting care is an important next step. More specifically, determining methods of further implementing TBI screening as well as addressing TBI-related sequelae in these Veterans may be a pragmatic and necessary approach.

BACKGROUND: Acquired brain injury (ABI) is a leading cause of death and disability among children and adolescents, who experience a variety of cognitive, motor, and functional impairments. These youth are at an increased risk for additional injury in the home and community environments.

OBJECTIVE: We aim to identify the home safety concerns adolescents with ABI, caregivers, and healthcare providers have for these adolescents with ABI.

METHODS: We recruited healthcare providers, adolescents with ABI, and caregivers of adolescents with ABI for this mixed-methods study. Participants completed questionnaires on demographics (including injury severity) and pre-identified home safety hazards. They also engaged in individual or group interviews to examine their clinical/rehabilitation experiences and home safety hazards and concerns. Finally, they participated in a self-identified hazard prioritization matrix activity. Questionnaire data were analyzed with descriptive statistics (mean, standard deviation, frequency, etc.), and interview recordings were transcribed and analyzed via qualitative thematic analysis. Matrix data were analyzed with both descriptive statistics (hazard frequencies) and qualitative analyses (coding and thematic analysis of hazard descriptions).

RESULTS: Participants included thirteen healthcare providers (30.8% OT, 30.8% PT, 23.1% SLP, mean age 37.5 years), five adolescent patients with TBI (mean age 15.2 years), and five caregivers of adolescents with TBI (mean age 46.2 years). A percentage of the 67 pre-identified hazards were rated as concerning by at least one participant (100% providers, 26.9% caregivers, 31.3% patients). Self-identified safety hazards were 59 for providers, 21 for caregivers, and 10 for patients. In addition, 60% of patients identified no hazards, as compared to every provider and caregiver participant self-identifying at least one hazard. We found seven themes in hazards: hazardous activities, hazardous situations, hazardous objects, hazardous others, hazardous spaces, harms, and patient-specific factors (e.g., impulsivity).

DISCUSSION: This research study elucidates the safety hazards that pose risks to adolescents with ABI after hospital discharge to their homes. While all stakeholders expressed concerns for this population, providers identified more hazards and higher levels of concern than patients and caregivers. These findings provide insights to improve home safety interventions delivered to adolescents with ABI and their families.

BACKGROUND: Acquired brain injury (ABI) is a leading cause of death and disability among children and adolescents, who experience cognitive, motor, and functional impairments. These youth are at an increased risk for injury in the home and community environments. However, few tools exist to reduce the risk of injury.

OBJECTIVE: We aim to assess the usability, usefulness, and desirability characteristics of a previously developed home safety program, the Home Healthcare Virtual Simulation Training System (HH-VSTS), and then identify modifications to tailor the program to adolescents with ABI.

METHODS: Individual or multiple participants viewed a real-time demonstration of the HH-VSTS or test-played it themselves. They simultaneously participated in semi-structured, recorded interviews that elicited suggestions for program improvements. Healthcare providers, adolescents with ABI, and caregivers of adolescents with ABI were recruited to participate in this mixed-methods study. Participants completed demographics (including injury severity) and HH-VSTS usability (examining usability, usefulness, and desirability) questionnaires. Transcriptions from the interviews were analyzed via qualitative thematic analysis, and questionnaire data were analyzed with descriptive statistics.

RESULTS: Participants included thirteen healthcare providers (30.8% OT, 30.8% PT, 23.1% SLP, mean age 37.5 years), five adolescent patients with TBI (mean age 15.2 years), and five caregivers of adolescents with TBI (mean age 46.2 years). On a 1-7 numeric rating scale with 1 as not demonstrating that quality and 7 as very demonstrative of that quality, all participants rated the HH-VSTS as having good usability (mean 5.48/7), usefulness (mean 6.09/7), and desirability (mean 5.52/7). Patients consistently rated these qualities high, while clinicians and caregivers rated them lower. Themes were modifications to enhance HH-VSTS characteristics: learning, enjoyment, graphics, content, usability, and utility.

DISCUSSION: We confirmed that participants, and particularly the intended user group, rated overall usability as moderate. We identified necessary modifications to improve the relevance, accessibility, and enjoyment of the HH-VSTS for adolescents with ABI. These findings provide insights to tailor the HH-VSTS for adolescents with ABI, while supported by their families and providers. Future research is anticipated to re-design, re-develop, and assess a revised HH-VSTS for this population. There are no conflicts of interest.

AM was a complicated 8-year old female with a three year history of intractable seizures unresponsive to numerous medications. Born a 25-week micropreemie, twin B, she suffered a bilateral intraventricular hemorrhage grade III/IV on day 2 of life resulting in hydrocephalus. By age 5, she had twelve brain surgeries, all related to hydrocephalus, before she developed new onset left hemisphere focal seizures. Following two unsuccessful thermal ablations of her left amygdala and hippocampus, the decision was made to undertake a functional hemisphereotomy, isolating her left hemisphere. Starting one month prior to surgery and continuing without interruption, the patient's mother instituted a regimen of twice daily supplementation using an omega-3 fish oil product that also contained Curcumin Extract, N-Acetyl-Cysteine, and Reduced L-Glutathione. The eight-hour surgical procedure went without complication.

Normal protocol dictates three days in the PICU, one week on the neuro-ward monitoring CSF output, fever, and edema, all very common following this procedure. Following removal of the externalized drain, patients typically spend an additional two to six weeks in inpatient rehabilitation. This patient, however, asked for, and ate, a full meal immediately upon waking, spent only one night in PICU, and as she was ambulatory the next day, she was transferred to the neuro-ward. Instead of three to five days of edema and fever as is typical, the patient had less than 24 hours of edema, no fever, and drain was removed on day three making her eligible for discharge to home for outpatient rehabilitation. However, due to COVID, outpatient rehabilitation was unavailable, so the patient was kept for one-week inpatient rehab. No further seizure activity has been noted since, now over three years later, and has been off all medications for over two years.

Here we present a case of arguably the most radical neurosurgical intervention that typically requires minimum of three weeks hospitalization. In this particular instance, the outcome was dramatically altered where the patient was proactively placed on an anti-inflammatory supplement regimen before, during, and after hospitalization resulting in her eligible for discharge to home in three days instead of three to eight weeks.

INTRODUCTION: The eTherapy app was created through a collaboration of computer engineering and occupational therapy and developed for patients with orthopedic injuries working on motor re-education. The app uses motion capture technology and a brand of inertia measurement units called Notches to measure a range of motion (ROM) and response time. The Notches are attached to the patient on both sides of a targeted joint and connected through Bluetooth to the mobile device with the app. This study finds novel uses for this app in patients with traumatic brain injuries. Concussion clients can experience long-term symptoms, including visual gaze deficits and changes in reaction time. They can also experience behavior or personality changes, including increased susceptibility to frustration¹.

METHODS: Researchers utilized a case study methodology with an expert opinion process². The eTherapy app was introduced to an occupational therapist (OT) specializing in concussion rehabilitation and demonstrated its current capabilities. Then, researchers conducted a semi-structured interview with the OT about using the app for clients with vision deficits.

RESULTS: In the interview, the therapist reported that the current functioning of the app and its crashes would increase frustration in concussion clients and slow down their progress. Through collaboration with the researchers, a method was developed to assess visual tracking by placing one sensor on the forehead and one on the back of the hand. The therapist also reported that the app's margin of error when measuring ROM should be decreased. With the changes made, the OT believes that the app could be a useful tool for this population³. The app is portable and inexpensive, making it appropriate to use both in-clinic and as part of a home program.

CONCLUSION: Through expert opinion, we determined that if this app is to be utilized in a population with post-concussion visual gaze deficits, it should be further developed. It is viable to continue the development of the app in-clinic or in a home program with a client in this population. The app can calculate data for visual tracking and reaction time to gather objective information in real-time. The app’s final development must be consistent in its utility and function without the application crashing.

References:
1. Scorza KA, Cole W. Current Concepts in Concussion: Initial Evaluation and Management. Fam Physician. 2019;99(7):426-434
2. Bayona-Ore L, Zavala R, Cruz M. Expert opinion process: applications in education. Paper presented at Proceedings of the 10th International Conference on Education Technology and Computers 2018. NY, USA; 2018:172-176. doi: 10.1145/3290511.3290519.
3. Mannino RG, Arconada Alvarez SJ, Greenleaf M, Parsell M, Mwalija C, Lam WA. Navigating the complexities of mobile medical app development from idea to launch, a guide for clinicians and biomedical researchers. BMC Med. 2023;21(1):109. Published 2023 Mar 23. doi:10.1186/s12916-023-02833-7

Social work education in the United Kingdom is governed by four regulatory bodies with no common curricula, with Social Workers in England alone undertaking multiple education routes in 82 higher education institutions (HEI). A growing body of evidence has demonstrated a potentially significant gap in Acquired Brain Injury "ABI" curricula inclusion in initial social work education. Little is known about the gap at a micro curriculum level or Social Work Educators' views of Acquired Brain Injury relevance in initial education. An intra-disciplinary, UK wide NIHR funded project, Heads Together, is researching social work education curricula to evidence the preparedness of graduating social workers for Acquired Brain Injury practice and to develop resource database for curricula development. As part of the research project, a 12-point online survey was deployed to UK-based Social Work Educators with the support of the Joint Universities Social Work Committee (JUSWEC) and the British Association of Social Workers (BASW). Thematic analysis of 28 responses found four key themes: 1) an acknowledged gap in ABI curricula inclusion in initial social work education including that of respondents; 2) significant numbers of respondents had personal experience of ABI (self, family or close friends); 3) majority view ABI should be mandatory part of initial social work education; and finally, 4) there are pockets of good practice often prompted by local practice. The survey findings will, in combination with interviewing newly qualified, specialist and commissioning social workers, inform curricula inclusion of ABI in social work education in the UK. Underpinning and guiding the project is a governance board of experts by experience including people with brain injury, family, and brain injured social workers.

CASE DIAGNOSIS
Opioid weaning in a patient with anoxic brain injury and an extensive hospital stay.

CASE DESCRIPTION
A 33-year-old male with an anoxic brain injury, related to complications after a gunshot wound (entry through ear into posterior cervical spine) was admitted to our hospital after discharge from a long-term care facility. He had tracheostomy, gastric feeding tube placed and was ultimately ventilator dependent. Upon nearing his discharge from prolonged hospital stay, our PMR/Pain management team was consulted. His pain regimen included Hydromorphone 0.5 mg Q4H prn, Acetaminophen 650 mg Q6H, Methocarbamol 1000 mg Q8H prn, Gabapentin 300 mg TID, and a Fentanyl patch 75 mcg/hr Q72H. Hypotension was an issue and made pain control even more challenging. Our goal on hospital discharge after nearly 273 days of admission was to be off intravenous medications and to reduce his overall morphine equivalent dose. We evaluated pain primarily via facial grimacing, as communication was limited due to his orientation, and his tetraplegic status. His total pre weaning morphine equivalent dose was 279. Over the course of 5 days, we were able to reduce morphine requirements to 150, while eliminating his intravenous medications.

DISCUSSION
Opioids should be used sparingly and every attempt for weaning should be made possible. They have been shown to further complicate treatment, worsen respiratory/cognitive status and have known to become an issue when attempting to wean if they have been administered over long periods of time. Additionally, higher morphine equivalent doses can lead to suppressed respiratory drive, dysautonomia, and decreased arousal, all issues we try to avoid potentiating in traumatic brain injury. Painful syndromes are characterized in traumatic brain injury and are challenging to diagnose, treat, and witness responses to treatment. Although localization may be difficult with nonverbal patients, we can use family, nursing staff, and physical examination maneuvers while monitoring for grimacing, blood pressure fluctuations, and mentation changes. Conservative pain relieving options include pressure relief, correction of posture deficits, bracing, manual therapies, and non-opioid medications. If these fail, we do resort to the use of opioids and suggest beginning with the least restrictive dose, limiting progression or increases to tolerance.

CONCLUSION
Opioid weaning strategies should be employed early on in the treatment plan and attempted several times over. It can be discouraging and so we suggest slow weaning protocols varying from 10-20% reductions over the course of several days in a supervised setting.

PURPOSE: In recent years, the incidence of traumatic brain injury (TBI) in Canada has doubled, with females having a higher prevalence. Current literature shows no consensus regarding how gender may influence post-TBI outcomes, thus prompting further investigations. Here, we sought to study whether gender impacts post-TBI outcomes specific to psychiatric well-being.

METHODS: A retrospective cohort study of patients admitted to St. Michael’s Hospital for TBI was analyzed. Using health consultation reports, we collected patient demographic characteristics, cause of TBI, past medical history, diagnoses following TBI and treatments. All measures analyzed were qualitative and coded as no or yes (e.g. suffered from depression: no or yes). Chi-square tests were used to assess whether males or females had differing TBI. Multiple comparisons were corrected for using the Bonferroni Correction.

RESULTS: Data was collected and analyzed for 39 patients (n=16 males, n=23 females, mean age = 38.5 ± 12.7 years). The causes of TBI included 16 (41.0%) motor vehicle accidents, 8 (20.5%) pedestrian accidents, 3 (7.7%) bicycle accidents, 10 (25.6%) cases of falls, 5 (12.8%) cases of physical assaults, and 3 (7.7%) sports-related injuries. Long-term disabilities resulting from TBI occurred in 14 patients (35.9%). Females were significantly more likely to experience orthopedic issues resulting from TBI compared to males (X2 = 5.35, p = 0.021), but this significance did not make it past multiple comparison corrections. No other significant differences were noted.

CONCLUSION: We did not find better post-TBI outcomes specific to psychiatric well-being in either gender in this pilot retrospective analysis. A larger sample and quantitative data are necessary to substantiate the findings.

KEYWORDS: Traumatic brain injury, gender comparison, quality of life

Patients with disorders of consciousness (DOC) are a population within the rehabilitation team’s scope of practice, but about whom limited education may be available to the therapy staff designated to support them. This was recognized as an area for development and efforts were undertaken to support more systematic, effective, and evidence-based approach to evaluation and treatment. This presentation will describe the development and implementation of procedures for allied health staff's involvement in evaluating and treating patients with DOC. A survey with eight questions was distributed to 18 therapy staff at Mayo Clinic in Rochester, asking them to rate their confidence level in evaluating, treating, and reporting results to medical staff or patient’s family. Staff rated their confidence level on a scale of one-five where one was “not confident requires full supervision” and five was “confident, provides training to others.” We asked each participant to rate their familiarity with terms associated with this patient population, where one was “this term is unfamiliar” and five was “I could provide education on this term.” Of 18 therapy staff, 15 responded and their data is included here. Initial data gathered indicates 66.7 percent of occupational therapists (OT), physical therapists (PT), and speech-language pathologists (SLP), who are currently evaluating/treating these patients feel they require some level of supervision and are not independent. 86.7 percent reported that they were not confident in reporting the results of their evaluation to other medical professional or patient’s family. Lastly, 26.6 percent of participants reported no training outside of what was provided in their curriculum or did not have education specific to DOC in their program, and 40 percent reported no additional training outside of on-site orientation/mentorship. Despite limited experience and education, the expectation is to provide quality care to patients with these complex diagnoses. This gap in knowledge and comfort revealed therapeutic approaches that were inconsistent across the therapy team and did not align with the recommended best practice guidelines published in 2018. To optimize knowledge and therapeutic skillset within the interdisciplinary team, this cohort of 18 rehab professionals (OTs, PTs, and SLPs), were identified and education and training was provided on evaluation measures (JFK Coma Recovery Scale Revised) and therapeutic interventions. As this is an ongoing project, post implementation data will be collected and used to develop an objective and defined evidence-based training protocol for all subsequent treating clinicians that aligns with published best practice guidelines.

BACKGROUND: The impact of post-concussion syndrome (PCS) on cognitive and motor abilities in ex-contact sports players is increasingly recognized. Research has predominantly focused on elite athletes, leaving a gap in understanding PCS's functional effects in the general population.

OBJECTIVE: Our research aimed to thoroughly examine neuropsychological outcomes and balance control in ex-athletes from non-professional backgrounds, with a focus on the enduring consequences of PCS symptoms.

METHODS: We conducted an extensive neuropsychological assessment to evaluate cognitive functions and utilized a dual force plate system to measure centre-of-pressure (COP) displacement and velocity, considering age and education as covariates.

RESULTS: Participants with PCS showed notable impairments in visual-spatial skills, immediate memory, and episodic memory. Regarding balance, no significant differences were observed in basic stances between the groups. However, under more challenging conditions, such as on uneven surfaces or during cognitive multitasking, the PCS group exhibited significant instability. This was particularly evident in medio-lateral balance during proprioceptive tests and in conditions of sensory limitation.

CONCLUSION: This study sheds light on the complex challenges former athletes with PCS encounter. The interaction between cognitive function and balance control, especially in demanding scenarios, highlights the necessity for individualized intervention strategies. These insights lay the groundwork for further investigations into the underlying mechanisms and potential treatment options for PCS in former athletes.

KEYWORDS: Post-concussion syndrome, neuropsychological outcomes, cognition, postural control, centre-of-pressure, former contact sports athletes

Background: Communication skills, while often overlooked in the rehabilitation of adults with mild traumatic brain injury (mTBI) are critical to successful community reintegration and re-entry into society. Assessment of language is often challenging in mTBI due to the lack of available sensitive and specific published tools (Duff et al). Recently, the use of story-telling discourse assessment has been explored in mTBI (Norman et al, 2020) but there is limited research on the expected performance of adults who speak a second language. In the US in particular, it is critical for clinical providers to understand the role of second language proficiency in order to accurately assess patients and plan treatment.

Methods: A main concept analysis (MCA) was implemented on “Cinderella” story re-tell samples of thirty-six participants with mTBI to quantify the accuracy and completeness of the story-telling using a well-validated task. The participants were divided into three groups (individuals who learned Spanish before the critical age of seven; individuals who learned Spanish after seven years; individuals who consider themselves monolingual). Relevant concepts based on the story were identified and scaled according to a coding system. Participants were assigned codes based on if key concepts of the story were included in their story-telling discourse and the level of accuracy in their performance.

Results: The final sample included 20 individuals who identified as bilingual before age age seven, seven bilingual individuals who identified as bilingual after age seven and eight monolingual individuals. Preliminary analyses indicated that mean MCA scores for the individuals who identified as bilingual before age seven outperformed the sequential and monolingual individuals, however, statistical significance was not reached. Further linguistic and grammatical analyses are underway to determine if differences at the microlinguistic level exist.

Discussion: The precise measurement of language performance after mTBI is currently elusive, as traditional language tests fail to sufficiently capture linguistic changes specific to mTBI. For individuals who speak one or more languages, assessment is further complicated however, this study is a first step in understanding these differences which in turn can help refine and optimize rehabilitation approaches for individuals from a variety of cultural and language backgrounds.

BACKGROUND: Recent studies have shown that concussion may lead to clinical impairment of the oculomotor pathways, and this has led to increasing research in the clinical assessment of post-concussion oculomotor dysfunction and its roles in diagnosis and treatment of concussion.

METHODS: All experimental procedures were approved by the Committee for the Protection of Human Subjects (CPHS), the defined Institutional Review Board (IRB) of University of California, Berkeley, and followed the tenets of the Declaration of Helsinki. Intercollegiate athletes at the University of California, Berkeley were asked to participate in an oculomotor assessment at baseline and after a concussion. All recruited athletes were clinically determined to be free from acute or subacute concussion at the time of the baseline examination by the team physician and diagnosed with a concussion by the same team physician. All post-concussion oculomotor assessments were evaluated 0-5 days post-injury (average of 2.55 days). All baseline and post-concussion eye examinations were conducted by the same optometrist and included a comprehensive clinical test battery to assess fixation, accommodation, vergence, saccades, smooth pursuits, versions, and vestibular-ocular reflex.

RESULTS: A total of nine subjects (age 18-22 years; two female; seven male) were evaluated for this case series. Five of these subjects had a history of a previous concussion, with the number of previous concussions per subject ranging from 1-5, with an average of 2.0. Paired statistical comparisons of baseline versus post-concussion binary measures (fixation, saccades, pursuits, and versions) as well as nineteen continuous function variables (fusional vergence, near point of convergence, near point of accommodation, accommodative facility, and DEM subtest values) did not reveal statistically significant differences among the individual oculomotor metrics, possibly because of limited sensitivity due to the small sample size. When comparing the baseline data to clinical norms, seven of the nine subjects (77.8%) exhibited a pre-existing oculomotor abnormality. Of those seven, all had additional oculomotor abnormalities post-concussion when compared both to clinical norms as well as to their individual baseline assessments.

CONCLUSION: Changes in oculomotor function from baseline data following concussion in this case series provide clinical evidence in support of the hypothesis that concussive injury itself causes oculomotor dysfunction beyond possible pre-existing abnormalities. Without the baseline data in this case series, a number of these subjects would have been misdiagnosed post-concussion with symptoms that were based on pre-existing oculomotor abnormalities, and this could have delayed their return-to-play. Given increased use of oculomotor assessments in concussion diagnosis and management, this case series demonstrates the value of baseline assessments for increasing the accuracy and utility of oculomotor metrics in concussion management decisions.

INTRODUCTION: Refractory postural instability is among the most challenging conditions, given the complex subsystems integrating into postural control. The rehabilitation of postural dysfunction relies on various assessments and treatment modalities, both low and high-tech, to address deficits in variably weighted sensory or motor subsystem inputs. Dynamic computerized posturography is a reliable, objective metric to assess postural stability in varying testing conditions. These scores are expressed as a percentage of the theoretical limit of stability. There needs to be more information regarding the use of computerized posturography to help direct interventions. This retrospective study aims to determine the efficacy of computerized posturography in informing therapeutic strategies. Specifically, in this cohort, the percentage stability score was used to help guide the rehabilitation mechanism (feedback, feedforward, or efferent copy), as well as the laterality of the treatment application to optimally engage the activity map of the cortico-cerebellar loops underlying motor planning.

METHODS: The subject population with loss of postural control included migraine headaches (23.1%), post-concussion syndrome/traumatic brain injury (37.5%), dizziness/vertigo (21.2%), dysautonomia (2.9%), post-traumatic orthostatic tachycardic syndrome (2.9%), and other brain disorders (12.5%) as the primary diagnoses. The pre-treatment posturography stability scores were compared and the direction of head rotation with the greater stability score dictated the side of individualized Cortical Integrative Therapy (CIT) treatment. Post-treatment posturography stability scores were taken over the intervention course (mean = 3.77 weeks, range 1 day to 20.29 weeks). Analyses considered the laterality of treatment, pre- and post-treatment stability scores, and the primary diagnosis.

RESULTS: The efficacy of the CIT treatment was indicated by over a 10% improvement (P < 0.001) in the mean post-treatment posturography stability score. Treatment ipsilateral to head rotation with the greater stability score produced near-equal results in all head positions. For example, the mean post-CIT treatment stability scores were comparable to the manufacturer's normative data (CDP range of 69.8 to 74.9) for perturbed stability, eyes closed testing conditions. While improvement was observed with all primary diagnoses, the percent of control calculations (post-treatment score ÷ pre-treatment score X 100) indicated that patients with a primary diagnosis of dizziness/vertigo had the greatest improvement in stability scores (nearing 150% of control).

CONCLUSION: The stability score-informed intervention strategy, predicated on posturography results, optimized the efficiency of the motor planning loop. Based upon the level of compromise, the posturography stability scores can direct the laterality of treatment application in real-time. Further study of the use of dynamic posturography can identify its potential role in informing treatment strategies to improve the dysfunctional loop mechanisms.

Acquired brain injuries (ABI) can result in sequelae across multiple systems and domains that disrupt and impact the individual’s interactions with the environment, thus affecting behavioral relations. The term “neurobehavioral” is used to classify a wide array of challenging excesses and/or deficits of behavior resulting from ABI, that impact or impede an individual’s progress in rehabilitation and recovery, and can ultimately pose safety concerns for the individual and caregivers. This presentation will include a discussion of how evidence-based, behavior analytic principles and practices can be applied at multiple levels of treatment, e.g. to address individual behaviors, in support of interdisciplinary collaboration, and to underpin case conceptualization. Two case studies will be presented to illustrate these areas of application and involvement, including data to highlight and support efficacy.

The first case study calls attention to the significance of the behavioral history of adults with ABI, which may include challenging behaviors pre-injury that can be exacerbated post-injury and complicate treatment planning and programming. The subject of this case study had a pre-injury history of physical and emotional trauma, as well as a diagnosis of borderline personality disorder, that required both inpatient and outpatient treatment. Following an ABI in their late twenties, resulting from a rollover car accident at high speed, pre-injury repertoires and sensitivities were profoundly disrupted and at-risk behavior occurred at high levels across all dimensions and settings during rehabilitation. The principles and practices of behavior analysis helped to inform medication adjustments that proved instrumental in stabilization efforts, and guided the acquisition and generalization of replacement behaviors that established readiness for access to the community and an eventual discharge to home.

The second case study will demonstrate how behavior analysis can play a less direct, but no less valuable role, in the rehabilitation process. A married, middle-aged individual with adult children, working in a management capacity at the time of injury, sustained an ABI in a pedestrian vs. motor vehicle accident. Efforts in acute and post-acute rehabilitation were significantly impacted by sequelae such as confusion, suspiciousness, paranoia and delusionality. This required management of non-reality-based behaviors and close monitoring of medical and behavioral stability, which in the post-acute phase included disrupted sleep, disorientation, irritability, at-risk wandering/mobility, etc. Throughout the rehab process, data collection and analysis supported medication considerations and adjustments. Eventually, following stabilization, behavior analytic input helped to guide systematic efforts to generalize behavior to the community and to establish readiness for a successful return home.

These case presentations represent programming and treatment efforts to address complex neurobehavioral sequelae in an intensive, residential, post-acute rehabilitation setting. Overall, key points of discussion will include data collection, challenging behaviors, specific treatment interventions to promote stabilization and readiness, interdisciplinary collaboration, and medication-related decisions.

We employed a mixed-method design (n=18) to investigate an innovative educational approach for allied healthcare professionals. The study centers around an escape room experience, where occupational therapy doctorate, doctor of physical therapy, and speech-language pathology graduate students collaboratively tackle a traumatic brain injury (TBI) case through puzzle-solving. The case was meticulously designed to address the knowledge required for interprofessional treatment of TBI. Puzzle scenarios encompassed assessments, impairments, and functional outcomes post-TBI, incorporating tools such as Rancho Los Amigos Levels of Cognitive Functioning Scale, Brunnstrom Stages of Stroke Recovery, Berg Balance Scale, aphasia symptoms, and patient management. Pre- and post-measures utilized the SPICE-R2 questionnaire, followed by structured focus group discussions. We averaged scores on the SPICE-R2 to create a full-scale composite, as well as composites for each of the three subscales for both the pre- and post-escape room surveys. We submitted the scores to a repeated measures t-test for each of the four pairs of composites and found significant increases in scores on four measures from pre-test to post-test, all ts < 3.20, all ps < .005. Qualitative analysis of narrative data obtained from focus group sessions unveiled two strong themes. Theme one: enjoyable educational approach. Participants expressed their enjoyment of the experimental learning format and this edutainment approach. Theme two: improved understanding of interdisciplinary contributions. This theme highlights the effectiveness of teamwork and the acquisition of insights into perspectives by other professions. The incorporation of case-based escape rooms as a pedagogical tool holds promise in enhancing the education of allied healthcare professionals, facilitating holistic comprehension of TBI management and encouraging collaboration. Engaging in case-based activities during their training can potentially foster future interprofessional collaboration among healthcare practitioners. The long-term benefits to interprofessional cooperation are well documented and include favorable effects on patient outcome metrics, contentment with delivered healthcare services, and substantial cost reductions within the healthcare system. For a comprehensive evaluation of the long-term impact on knowledge acquisition related to TBI and interprofessional collaboration in clinical settings, further research in the form of a longitudinal study is warranted. This study holds potential in shaping future educational strategies in allied health professions, with applications in neurogenic disorders and beyond.

Following the motor vehicle accident, this two-and-a-half-year-old patient was rendered comatose, with a hospital admission GCS score of 8/15 and left frontal subdural haematoma associated with mild midline shift found on CT Brain Scan. Following conservative management and recovery from coma after 4 to 6 days, patient recovered from right-sided weakness but two years later displayed residual emotional and behavioural changes such as anger, regressed emotional attachment to his mother, indiscriminate aggression to familiar family members and social-emotional interaction problems. Patient underwent weekly sessions of family integration therapy with involvement of his mother initially, and with gradual introduction of his grandmother and thereafter his siblings into the therapeutic setting for a period of 12 months, using the Infant-Toddler Social and Emotional Assessment (ITSEA) as per-and post-treatment tool to assess changes. Patient’s emotional balance and behavioural control showed improvement within the family setting the stage on the ITSEA, This paper outlines the remediation of emotional and behavioural changes in a young TBI patient in a family setting.

Beliefs and perceptions about health can affect healthcare engagement, treatment adherence, and health outcomes. The Multidimensional Health Perceptions Questionnaire (MHPQ) was designed to assess: 1) health perceptions about the causes and consequences of health conditions; 2) the benefits and barriers to maintaining and improving health; 3) how to best accomplish health-related goals and control health circumstances; 4) the role of religion and/or spirituality in healthcare, perceived discrimination and its effects on care; 5) and trust in healthcare providers. Prior research in a mixed clinical and general population sample showed the MHPQ had a high content validity index of 98.1% and factor structure with seven domains. Items in seven health perceptions domains, or subscales, are averaged to produce a score ranging from 1 (low agreement) to 5 (high agreement). These subscales are: Anticipated Discrimination and Judgement, Spiritual Health Beliefs, Social and Emotional Well-being Beliefs, Confidence and Trust in Healthcare providers and Medicine, Health Self-Efficacy, Trust in Social Health Advice, and Health Literacy. The objectives of the current study are to validate the MHPQ among persons with traumatic brain injury (TBI) and characterize their health perceptions profiles to healthcare communication via a multisite study in five TBI Model Systems centers in the United States. Herein we present preliminary data from that study on the internal consistency of the MHPQ (English version) subscales, as well as descriptive characterization of these health perceptions domains among persons with chronic TBI. Forty-eight participants, at least one year after moderate-to-severe TBI, completed the MHPQ once (85.4% via electronic survey, 14.6% via telephone interview, with an average completion time of 9.2 minutes). Participants in the sample were 19-79 years old (mean=46.0) and were mostly men (64.6%), Non-Hispanic/Latino (85.4%), and White (64.6%). Internal consistent reliabilities (Cronbach’s α; >.70 considered “good”) and descriptive characterization of the domains [mean (M), standard deviation (SD), range (R)] were as follows: Anticipated Discrimination and Judgement (α=.90, M=2.1, SD=0.6, R=1.0-3.5); Spiritual Health Beliefs (α=.89, M=3.1, SD=0.8, R=1.2-4.6); Social and Emotional Well-being Beliefs (α=.79, M=3.5, SD=0.7, R=1.4-4.6); Confidence and Trust in Healthcare Providers and Medicine (α=.72, M=3.7, SD=0.4, R=3.1-5.0); Health Self-Efficacy (α=.75, M=3.9, SD=0.5, R=2.5-4.9); Trust in Social Health Advice (α=.83, M=2.8, SD=0.8, R=1.3-5.0); and Health Literacy (α=.86, M=4.1, SD=0.5, R=2.2-5.0). Findings support that the MHPQ has good to excellent internal consistency reliability across its subscales and that it captures a range of health perceptions in a relatively short amount of time. Understanding health perceptions of those with TBI is a critical first step towards personalizing communication and intervention approaches to be responsive to diverse individuals across cultures and populations. These findings can be used to provide healthcare professionals with information that can guide communications with people with TBI to be more personalized and culturally humble.

A 47-year-old male presented to acute inpatient rehabilitation with a moderately severe traumatic brain injury (TBI) 12 days after falling off a retaining wall. Initial neuroimaging demonstrated extensive orbitofrontal and bitemporal hemorrhagic contusions, and intraventricular hemorrhage. Other injuries included skull fracture and T12 compression fracture with resulting severe headache, back pain, right sided hearing loss, and vision problems. Physical examination was remarkable for bilateral chemosis and injected sclera. Pupils were equal, round, and reactive to light with accommodation. Extraocular movements displayed impaired lateral and dysconjugate gaze bilaterally. There was right facial weakness with injection of the right eye. Accordingly, neuro-ophthalmology was consulted. On ocular examination, a corneal ulcer was demonstrated in the right eye. After pupillary dilation, photo-retinography demonstrated impressive papilledema. RI/MRV of the brain revealed impressive bilateral temporal and frontal hemorrhagic contusions with no evidence of sinus thrombosis. The patient eventually recovered after symptomatic treatment.

OBJECTIVE: To determine rates of return to driving following traumatic brain injury (TBI) and explore driving patterns and crash rates pre- and post-injury.

METHOD: Adults (N = 334) with moderate-to-severe TBI enrolled by eight TBI Model System sites. A driving survey was completed during inpatient rehabilitation (for pre-injury information) and at one- and two-years post-injury.

RESULTS: Rates of return to driving were 65% at one-year follow-up and 70% at two-year follow-up. Return to driving was associated with higher levels of family income. Frequency of driving and distance driven were diminished compared to pre-injury as was frequency of driving in risky conditions (heavy traffic, bad weather, at night). Crash rates were 14.9% in the year prior to injury (excluding the crash that resulted in TBI), 9.9% in the first year post-injury, and 6% during the second year post-injury. Post-injury, the odds of a participant having at least one crash was decreased by 40% (95% CI: 15% - 59%) per year (p=0.005). Amongst participants who endorsed crashes in the year prior to their injury, the average number of crashes reported was 1.57 (77 crashes reported by 49 participants). At follow-up, these averages were 1.50 for the 1-year follow-up (i.e., 18 crashes for 12 participants) and 1.33 for the 2-year follow-up (i.e., 12 crashes by 9 participants). Logistic regression examining those who did or did not experience a crash did not reveal any significant findings for Year One. At Year Two the only significant finding was for participants’ time to follow commands. Those with milder injuries were more likely to experience a crash.

CONCLUSION: Consistent with prior reports, this investigation has shown that return to driving is a common occurrence following TBI, although individuals may limit their driving in terms of frequency of driving or total distances driven compared to pre-injury. Also, restriction of driving in particular situations is common. Incidence of crashes in this population is shown to be higher than population-based statistics, but this investigation highlights the critical importance of considering the possibility that, as a group, individuals who sustain a TBI are at higher risk of crash even prior to their injury. Discussion of crash risk needs to be tempered by the finding that 85% of those who returned to driving after injury did not report experiencing any crashes during follow-up interviews. Future work is needed to identify both premorbid and post-injury characteristics that may influence likelihood for adverse events while driving. Such studies will assist in development of screening tools and appropriate regulations to promote appropriate return to driving following TBI.

BACKGROUND: Postural orthostatic tachycardia syndrome (POTS) is a disorder of the autonomic nervous system which results in lightheadedness following a postural change from supine to standing upright and an associated rapid rise in heart rate. Other symptoms include physical and mental fatigue, exercise intolerance, anxiety, blurry vision, and headaches. POTS symptoms are often difficult to manage, as limited treatment options exist. Transcranial magnetic stimulation (TMS) is an FDA-approved treatment for depression and anxiety. We hypothesize that by addressing the anxiety symptoms of the POTS spectrum with TMS, other POTS symptoms may improve.

METHODS: Two patients with POTS underwent TMS treatment at Kaizen Brain Center. One received Kaizen’s Accelerated TMS (KATMS) protocol (ten, 1800-pulse iTBS sessions daily; 45-minute interval between sessions) for five consecutive days and the other received the regular POTS TMS protocol (one, 1800-pulse iTBS session daily) for thirty-five consecutive weekdays. Resting state fMRI (RS-fMRI) was used to individually target the region of the amygdala most associated with anxiety in each patient. Treatment was administered at each patient’s unique resting motor threshold. HRV, heart rate, cognitive fatigue, depression, and anxiety were measured and monitored using questionnaires and electronic devices at baseline, throughout treatment, and post-treatment.

RESULTS: Two weeks post-treatment, the patient that received KATMS experienced a 20% decrease in anxiety (measured during a follow-up visit), a 10-point increase in HRV (measured using the Elite HRV App), and a 7.5% improvement in orthostatic intolerance (measured by the NASA-10 Lean Test). This patient will continue to be monitored. The patient receiving the regular POTS TMS protocol is four weeks into treatment, and has already experienced a 13% improvement in orthostatic intolerance (measured by the NASA-10 Lean Test), as well as increased physical stamina and a rejuvenated appetite. Additional data will become available throughout this patient’s treatment and follow-ups.

CONCLUSION: TMS has shown some promise in addressing POTS symptoms.

Reference
1. Lisanby SH, Husain MM, Rosenquist PB, et al: Daily left pre- frontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. Neuropsycho-pharmacology 2009; 34:522–534
2. O’Reardon JP, Solvason HB, Janicak PG, et al: Efficacy and safety of transcranial magnetic stimulation in the acute treatment of major depression: a multisite randomized controlled trial. Biol Psychiatry 2007; 62:1208–1216
3. Levkovitz Y, Isserles M, Padberg F, et al: Efficacy and safety of deep transcranial magnetic stimulation for major depression: a prospective multicenter randomized controlled trial. World Psychiatry 2015; 14:64–73
4. POTS https://www.hopkinsmedicine.org/health/conditions-and-diseases/postural-orthostatic-tachycardia-syndrome-pots

Background:
Functional Neurological Disorder (FND), Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder are the main categories of Somatic Symptom and related conditions of the DSM 5. These conditions are recognized to occur following head trauma. Psychological factors associated with these conditions are thought to play a role in perpetuating some complications of mild head injury. The role of sensitizing physical events, such as trauma, is also thought to affect emerging psychopathologies of functional and somatic symptoms.

Objectives:
To evaluate potential differences in the pattern of functional and somatic symptoms and symptoms of illness anxiety in patients with mild head trauma in comparison to patients with the primary diagnosis of FND, SSD and illness anxiety disorder.
To explore whether any potential differences are related to the duration of the diagnosis.

Methods:
This is a retrospective data analysis of thirty-four patients with FND-SSD and illness anxiety disorder consecutively referred to a specialist neuropsychiatric service. The patients' somatic scales and subscales of the Personality Assessment Inventory (PAI) were analyzed and compared against a control sample of patients with FND-SSD without head trauma. These scale-subscales include overall somatic symptoms, somatization, conversion and health concerns. The results were subsequently stratified based on the duration of the illness.

Results:
There was a statistically significant difference specifically in the conversion subscale between the groups with and without head trauma, with a mean Conversion T Score of 66 in the former and 84 in the latter (p=0.012), denoting less severe conversion processes post-head trauma but equally severe somatization and illness anxiety pathologies in patients with and without head injuries. Patients with post-trauma diagnosis tended to have a mean duration of illness approximately four years shorter than patients with FND-SSD-illness anxiety without head trauma. We were not able to establish a statistically significant association between the duration of illness and the pattern of symptoms in patients with or without head trauma. The difference between the two groups may be related to the nature of psychopathological processes rather than duration.

Conclusions:
Patients with post-head injury FND-SSD may have some unique psychopathological and symptomatologic presentations of their SSD and related conditions.

Rates of traumatic brain injury (TBI) have traditionally relied on medical incidences to estimate prevalence. However, issues related to reporting and accessing medical care (e.g., unaware, uninsured, undocumented; Rao et al., 2020), charting medical encounters (e.g., unspecified head injury S09; Peterson et al., 2020), and diagnosis/definition (Patricios et al., 2023; Silverberg et al., 2023), have raised questions regarding the true prevalence of TBI in the community. Moreover, there have been organized efforts to move away from simple tripartite classification of TBI as mild, moderate, or severe to incorporating other severity indicators and risk stratification by outcome.
The present retrospective cohort study is an community-based surveillance methods that utilized three probability-based sampling methods for recruitment using a combination of mixed-mode random probability selection method using the United States Postal Service Delivery Sequence File (geographically stratified by population density; n = 25,000), Computer Assisted Telephone Interviewing technology (65% mobile/cellular; n = 15,000), random digit-dialing telephone recruitment of Californian participants (n = 10,000) of the National Behavioral Risk Factor Surveillance Survey, and quota-based recruitment method using registered California voter demographics.
In the total sample of California residents (N = 1,052), 42% self-endorsed a history of at least one event of any head/neck injury (M = 3.89, SD = 10.07), with 25% endorsing an associated period of lost consciousness (15% of sample). An average of three decades (M = 30.4, SD = 16.2) had elapsed since initial head trauma for the present sample, which were then compared on self-endorsements of cognitive, physical, and social dysfunction to the general California subgroup without head injury.
Ordinary least squared models were used to regress endorsements of employment difficulties, justice system involvements, and experiences with marginalized housing on endorsements of persistent depressive symptoms, generalized anxiety symptoms, neurocognitive disturbances, frequency of intoxication, presence of psychosis, and physical difficulties (e.g., ADLs) after controlling for age, gender, years of education, and income. All models significantly predicted the psychosocial outcome of interest with the head trauma estimates consistently ranking as a top predictor right next to frequency of intoxication for experiences with marginalized housing, presence of psychosis for justice system involvements, and difficulties with independently completing ADLs for employment difficulties. These findings provide initial evidence that suggests that complications associated with TBI manifest, over decades, as psychosocial dysfunction in a disease-like fashion. This may have a number of direct and indirect explanations, which in addition to a biological TBI signature, include lack of needed environmental supports (e.g., HCBS Medicaid) to manage cognitive and affective symptoms that may be ancillary to a brain injury, unfortunate community messaging (e.g., media, poor acute/post-acute medical management of symptoms and attributions), or inaccurate education about appropriate expectations and health-risk behaviors to enhance successful community reintegration following TBI.

INTRODUCTION: Homicide is one of the leading causes of maternal mortality in the U.S. and approximately half of these deaths are associated with domestic and intimate partner violence (DV/IPV). With medical advances, maternal obstetric complications have declined in recent years, however maternal mortality continues to increase in part due to violence. Research has shown that DV/IPV increases in both incidence and severity during pregnancy. Understanding that 74% of individual DV/IPV events include injury to the head and neck, including strangulation, it is likely that many women sustain peripartum concussions and abuse induced brain injuries (AIBI). Abuse induced brain Injury often presents with a depressed mood, difficulty concentrating, sleep problems, emotional lability, and/or fatigue, similar to the presentation of peripartum depression (PPD). Given the similarity of clinical symptomatology, are a subset of women with PPD actually suffering from an AIBI? In this review, we explore the association between peripartum depression, domestic violence, and brain injury.

METHODS: A PubMed search was performed from January 2016, the publication date of the U.S. Preventive Services Task Force Recommendation for postpartum depression screening, to July 2022 for keywords prenatal, peripartum, or postpartum depression combined with domestic and/or intimate partner violence. 120 articles met criteria for review to assess available prevalence data and associations between PPD and DV.

RESULTS: The mean prevalence of prenatal, peripartum, and postpartum depression was 25.0%, 17.7%, and 21.1% respectively, with an overall average of 23.5% and range of 5.8-50.5% across all groups. An average of 19.6% women experienced DV/IPV during pregnancy. Of the 98 papers that commented on DV/IPV, 73 (74.5%) found that DV/IPV was strongly associated with PPD. No papers commented on head injury, brain injury, or concussion surrounding pregnancy.

CONCLUSION: Our results show that approximately one in five women experience DV/IPV during pregnancy. While 74% of DV/IPV victims report head injury, to date, no studies have investigated DV/IPV-associated brain injury during the peri- or post-partum period. Given the significant similarities between AIBI and PPD symptoms, there is a critical need for research on the prevalence of peripartum abuse induced brain injury potentially including screening for peripartum brain injury with the current practice of peripartum depression assessment.

Moderate/Severe Traumatic brain injury (msTBI) often results in diffuse injury to white matter (WM), particularly to the corpus callosum (CC) (Dennis et al., 2015). Linking this CC vulnerability to cognitive outcomes has been more difficult given that CC function has been understudied and cognitive outcomes following msTBI are heterogeneous. This is an especially important problem for younger patients whose brains are in a period of ongoing rapid development. One indicator of CC function, which may mediate a link between CC structural integrity and cognitive outcomes, is interhemispheric transfer time (IHTT) (Ellis et al., 2016). Within pediatric msTBI samples, a bimodal distribution in IHTT exists, revealing a subgroup of children with either IHTT times comparable to healthy controls or significantly slower (Dennis et al., 2017). The IHTT subgroups demonstrate divergent trajectories of CC structural recovery as measured by Mean Diffusivity (MD) in the CC, an index of structural integrity measured by Diffusion Tensor Imaging (DTI). Both slow and normal IHTT subgroups showed worse MD in the CC in the post-acute timeframe after msTBI, but only the normal IHTT subgroup normalized MD in the CC at the chronic timeframe. Although in that study, IHTT subgroups did not differ on a broad index of cognitive functioning, another study showed that slow IHTT predicted worse cognitive outcomes post-acutely in pediatric msTBI (Moran et al., 2016). In this study, we aimed to reconcile these findings by testing whether IHTT could predict not only divergent MD recovery trajectories after pediatric msTBI but also more discrete cognitive outcomes.
In this study, 34 survivors of pediatric msTBI were compared to 45 well-matched controls (e.g., community members, uninjured siblings) on measures of IHTT, DTI, and standardized neurocognitive tasks of working memory. The sample was evaluated as early as one month (M = 4.18, SD = 2.24) following msTBI (baseline) and re-evaluated as far out as 24 months (M = 17.16, SD = 2.34). ANCOVA models with years of parental education, age, and gender as covariates revealed that trajectories (interaction) of structural WM improvement versus disorganization in CC projections (i.e., frontal, temporal, parietal), as measured by MD, matched the working memory scaled scores (age-adjusted) of the subgroups, F (2, 70) = 3.22, p = .046, ηp2 = .084. Neurocognitive and brain imaging biomarkers as stratified by an IHTT biomarker collected at an early stage of recovery post-msTBI resemble one another at baseline and one-year follow-up, suggesting that significantly higher MD is consistently associated with significantly poorer letter number sequencing at both time points for Slow IHTT, but not Normal IHTT. Future research will assess associations with adaptive behaviors, family factors, and functional outcomes to potentially identify which children may need more environmental/community support following msTBI in service toward successful reintegration.

INTRODUCTION: Reduction in participation in various activities (e.g., social, household) is a common functional outcome of traumatic brain injury (TBI) and is associated with lower quality of life (Goverover et al., 2017). The Community-Based Neuropsychological Rehabilitation (CBNPR) Model (Judd & DeBoard, 2009) emphasizes the importance of not only addressing individual deficits but also facilitating socio-environmental changes to improve the participation of individuals with neurological conditions during neuropsychological rehabilitation (NPR). Existing studies examined the effects of individual factors (e.g., mental health, pain, cognition) and socio-environmental factors on post-TBI participation separately (Kersey et al., 2020); research that investigates the interaction between the two is needed.

OBJECTIVES: the present study aims to 1) determine the effect of Insurance Provider on post-TBI Participation; and 2) examine the interaction effect between Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive Symptoms on Participation.

METHODS: CATBI registration packets that include relevant symptoms checklists, Mayo-Portland Adaptability Inventory Participation Index (M2PI), and Community Integration Questionnaire (CIQ) were collected from 229 survivors with TBI between 20 to 89 years old (M = 50.87, SD = 15.46). The participation of participants with Medicaid, Medicare, Medi/Medi, Commercial/Employer-provided/Private insurance was examined by a one-way MANOVA. A one-way MANCOVA was conducted to test the interaction effect of Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive Symptoms on Participation.

RESULTS: The combined Participations (i.e., M2PI and CIQ) of survivors with different Insurance Providers were significantly different (p < .05). Participants with Commercial/Employer-provided/Private insurance scored significantly lower on M2PI than participants with Medicare and Medi/Medi. There was a statistically significant five-term interaction between Insurance Provider, Depression, Anxiety, Physical Difficulties, Neurocognitive Symptoms (p < .001). However, after controlling for the covariates, the only significant difference lies between the CIQ scores of individuals with Medi/Medi and Commercial/Employer-Provided/Private insurance.

CONCLUSION: The significant five-term interaction between Insurance Provider, Depression, Anxiety, Physical Difficulties, and Neurocognitive symptoms supports the CBNPR model in terms of incorporating both individual-health and environmental factors to promote participation post TBI. The present study underscores the pivotal role of insurance providers in shaping post-TBI participation outcomes. Notably, participants covered by Commercial/Employer-provided/Private insurance experienced less perceived obstacles for participation. Insurance transformation, such as Enhanced Care Management, that extends beyond traditional healthcare to include community-based resources could facilitate the reintegration process following TBI. Future research should also investigate other socio-environmental factors to better understand their interaction with individual-health factors. The findings also highlight the need to incorporate physical, mental, and cognitive health support (e.g., by resource facilitation) in NPR to promote participation of individuals with disadvantaged socioeconomic status and disabling conditions.

Up to 40% of patients will suffer from 2 or more psychiatric disorders following traumatic brain injury (TBI)6. A positive correlation between Axis-1 affective disorders, such as major depressive disorder (MDD) and TBI has been identified by a growing amount of literature1. Seasonal affective disorder (SAD) is characterized in the DSM-V as a subtype of MDD, including at least 2 episodes of MDD in the last 2 years demonstrating evident seasonal variability and is marked by full remission at the end of the season (mostly associated with winter)2. However, there’s limited data investigating the relationship between TBI and SAD. Interestingly, proposed mechanisms for the pathophysiology of both SAD and TBI involve dysregulation of serotonergic pathways in the CNS3. Studies have shown that patients with SAD have an upregulation of SERT in the winter compared to healthy controls, causing less available 5-HT in the synaptic cleft and TBI has been associated with as much as a 17% loss of serotonergic neurons4,8,9. Using the Seasonal Pattern Assessment Questionnaire (SPAQ), a widely used screening tool for SAD, this study aims to determine if there is a significant difference in the results of the questionnaire in a population with TBI from the Ottawa Vista Centre for Brain Injury Services compared to a control group5. More specifically, we will be comparing the mean Global Seasonality Score (GSS) between the groups using ANOVA as well as the number of positive screens for SAD in each group. A positive screen for SAD is a GSS of 11 or greater with a score of “moderate” or higher on question 17 of the SPAQ7. Exclusion criteria include actively taking anti-depressants as well as ETOH abuse3. The control group consists of students at the University of Ottawa who volunteered to fill out the SPAQ. We hope the results of this study will help direct best practice guidelines in caring for people post-TBI by helping to understand what cognitive and psychiatric illnesses can impact their independent functioning by acting as a barrier to reintegration into the community.

Chronic brain injury is associated with specific neurological, medical and psychological conditions that may decrease an individual’s functional capacities, their ability to live successfully, return to school or vocational endeavors, affect their relationships with others, and alter an individual’s quality of life. Over the last decade, numerous clinicians and researchers have emphasized the importance toward implementing a Chronic Care Model to manage the long term and often lifelong sequelae of Brain Injury.¹ A model for service delivery was originally introduced by Masel and DeWitt ² who stressed the importance of systematic Brain Injury care that extends beyond the acute and inpatient rehabilitation phase of management. This would include proactive expectant management of the lifelong needs for patients, families and caregivers. timely and appropriate rehabilitation services, and addressing concomitant psychosocial issues such that individuals can maximize their capacities for community integration and societal participation. A formal and agreed upon standard of practice to evaluate and/or manage the complex needs of brain injury individuals and how those needs may dynamically change over time does not exist.
Aims: As part of the BeHEALTHY³ initiative, this feasibility project aligns with the goals of advancing a chronic disease management model for individuals with brain injury, their caregivers and health care providers. Following a systematic literature review, a BeHealthy working task force developed an easy to administer holistic and comprehensive intake tool for clinicians to utilize regardless of their specialty when managing the sequelae of chronic brain injury. Key concepts incorporated into the tool include:
1. A shared responsibility among the patient/family/caregivers and health care professionals emphasizing self-advocacy.
2. Promoting proactive and goal-oriented management plans aimed at meeting the dynamic and individualized needs of patients, families and caregivers.
3. Emphasize collecting relevant pre injury and post injury medical and psychosocial history including mental health.
4. Emphasize the importance of evaluating an individual’s sensory-motor, neurocognitive, behavioral, social, community integration and societal participation status.

Components of the intake tool entails a Pre-visit assessment obtaining salient demographic information, relevant injury history, past medical and surgical history, medications, allergies, past hospitalization’s, current health care providers, family, educational and social history and a functional review of systems. This pre-visit tool will prepare the clinical providers for an in-person, holistic, targeted and time efficient initial intake that can be followed by personalized components of a general medical exam, neurological exam and “problem-specific and/or targeted functional exam.” Utilizing qualitative research methods for tool validation, reproducibility, comprehensiveness and ease of use, this can equip clinicians with a systematic tool useful in developing both a short and long term integrated management plan that can serve as a foundation for lifelong management.

Objective: To determine if PRN antipsychotic or benzodiazepine medication administration is increased over the weekends as compared to weekdays.

Design: Retrospective chart review

Setting: Acute inpatient neurorehabilitation hospital

Subjects: Patients admitted for moderate-severe traumatic brain injury and prescribed antipsychotics or benzodiazepines for agitation and/or aggression on an as-needed basis between 1900 Friday evenings and 0700 Monday mornings.

Main Measures: Primary outcome was the comparison of average daily number of administrations and daily medication dose between weekly and weekend PRN antipsychotic or benzodiazepine administration for agitation or aggression.

Results: Fifty-Seven patients with a total of 4,485 PRN administrations were included in the chart review. On the weekdays, benzodiazepine had an average prn dose of 4.3 mg and antipsychotics had an average prn dose of 78.7 mg. The weekend days showed an average prn dose of 3.5 mg and 82.6 mg for benzodiazepine and antipsychotics respectively. Statistically significant differences were found with benzodiazepines where there were larger doses administered on the weekdays when compared to the weekend days on average. No statistical differences were found with the antipsychotic doses.

Conclusion: There was no significant difference found between weekday and weekend administration with prn medications indicated for aggression/agitation to support higher antipsychotic or benzodiazepine use on the weekends. Further research to explore the consequences of and the key components of a deleterious negative "weekend effect" whereby no formal rehabilitative therapies occur on the weekends is warranted for programs treating persons with traumatic brain injury.

Keywords: traumatic brain injury; neurorehabilitation, prn, pro re nata; agitation; aggression

Abstract: Neural Correlate of Affective Disorder in Patients with Traumatic Brain Injury (TBI)

Background: TBI leads to emotional dysregulation which is the inability to control one's emotions (Weis et al., 2022). Diffuse Axonal Injury (DAI) is a hallmark of TBI which can be screened using Diffusion Tensor Imaging (DTI) sequencing in MRI. The exact neural correlate is unclear. Some earlier studies suggested axonal injury in the anterior limb of the internal capsule involving the white matter tracts. (Floeter et al., 2014)

Objective: Does DAI in the genu of the corpus callosum based on MRI with DTI sequence lead to emotional dysregulation in patients with TBI?
This paper aims to support the claim that there is a pathological problem associated with emotional dysregulation rather than it being due to an underlying mood or personality disorder (Parvizi et al., 2009).

Methods: We analyzed clinical records of patients between 2017-2023 at Kaizen Brain Center who were diagnosed with TBI related emotional dysregulation by a TBI specialist. We found 18 patients who had abnormal DTI on their MRI and then probed their clinical notes for emotional dysregulation based on the physician’s impression.

Results: Of the 92 TBI patients, 18 were found to have DAI in corpus callosum and diagnosed with emotional dysregulation. However, we did find that abnormalities in the genu were not exclusive to this correlation. Decreased FA in the splenium and other areas of the body also correlated with emotional dysregulation.

Conclusion: Abnormal DTI results due to DAI in corpus callosum may be a neural correlate of emotional dysregulation found in TBI Affective Disorder.

Reference:
CL;, Weis CN;Webb EK;deRoon-Cassini TA;Larson. “Emotion Dysregulation Following Trauma: Shared Neurocircuitry of Traumatic Brain Injury and Trauma-Related Psychiatric Disorders.” Biological Psychiatry, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/34561028/.
Floeter, Mary Kay, et al. “Impaired Corticopontocerebellar Tracts Underlie Pseudobulbar Affect in Motor Neuron Disorders.” Neurology, U.S. National Library of Medicine, 12 Aug. 2014,
Parvizi J;Coburn KL;Shillcutt SD;Coffey CE;Lauterbach EC;Mendez MF; “Neuroanatomy of Pathological Laughing and Crying: A Report of the American Neuropsychiatric Association Committee on Research.” The Journal of Neuropsychiatry and Clinical Neurosciences, U.S. National Library of Medicine, winter 2021, pubmed.ncbi.nlm.nih.gov/19359455/.
Saddiqi, Shan. “Distinct Symptom-Specific Treatment Targets for Circuit-Based Neuromodulation.” Distinct Symptom-Specific Treatment Targets for Circuit-Based Neuromodulation, ajp.psychiatryonline.org/doi/epdf/10.1176/appi.ajp.2019.19090915

BACKGROUND: Concussions are a prevalent medical condition well recognized within professional and collegiate American football athletes, but less is known about the implications of concussions within adolescent populations. Recent studies indicate that approximately 67,000 high school football athletes are diagnosed with a concussion every year. Even with the high numbers of concussions diagnosed, high school football players may not adequately recognize or report the signs and symptoms of a concussion. Unrecognized and unreported brain injury should be of concern to health care providers given that adolescents experience longer and more diffuse cerebral swelling following neurological trauma compared to an adult population. Understanding the occurrence of concussions in high school American football athletes enables health care providers and coaches to properly assess adolescent athletes, while cultivating safer playing environments.

OBJECTIVES: The primary objective is to determine the occurrence of undiagnosed head trauma resulting from participation in high school football. The secondary objective is to understand why high school football athletes fail to recognize and report experiencing concussion-like symptoms.

METHODS: A five question anonymous online survey tool was shared with a cohort of high school varsity football players at a single institution. The survey includes questions regarding the participant’s concussion history, presence of unreported concussion symptoms, and questions allowing respondents to further elaborate on their attitude and knowledge of concussion symptoms.

RESULTS: Of 38 surveys shared, 81.6% (31 responses) were returned. While 90.1% of survey respondents reported having experienced concussion-like symptoms following a hit to the head during a game or practice within the most recent season, only 18.2% responded that they immediately left the field of play or sought medical attention. 12.9% of survey respondents were evaluated and diagnosed with concussion within the most recent football season. While 57% of survey respondents felt unable to determine if they may have had concussion symptoms, 35% of respondents who felt comfortable identifying their own concussions symptoms did not report them to a coach or trainer. The primary reason provided for not reporting recognized concussions symptoms was “fear of not immediately returning to the field of play.” Twenty-eight percent of study respondents reported that they experience prolonged concussion symptoms, lasting several weeks or even months.

CONCLUSION: While the majority of high school football players surveyed reported experiencing concussion-like symptoms, for many players the symptoms were not recognized and if recognized were not reported resulting in few players receiving standard medical treatment such as placement into a stepwise concussion protocol. Understanding why knowledge and attitudes about a concussion affects an individual's willingness to seek medical attention immediately following head trauma is crucial to developing new narratives of concussion diagnostics, establishing general concussion awareness, and preventing long term health consequences.

BACKGROUND: Traumatic Brain Injury (TBI) is a commonly identified condition in athletes, veterans, and car accidents, however, TBI in the domestic violence and intimate partner violence (DV/IPV) population is critically underrecognized. Current literature estimates 74% of these violent events result in mechanical trauma to the head, neck, and face. Additionally, half of these injuries further result in an ischemic brain injury caused by strangulation. Repeated head trauma has been linked to an increased risk of developing multiple sclerosis (MS), predominantly in cohorts of women and children. Approximately 38%-63% of women with MS report prior experiences of abuse, and abuse may lead to earlier onset of illness and higher relapse rates. There are no identified interventional studies that address DV/IPV-induced TBI in the MS population.

OBJECTIVE: The primary objective is to propose abuse-induced brain injury and strangulation as a physiologic risk factor for developing MS.

METHODS: A PubMed search of articles September 2014 to November 2023 using key words multiple sclerosis in conjunction with traumatic brain injury, head injury, concussion, and/or strangulation as well as domestic violence and/or intimate partner violence retrieved ten papers. Articles were reviewed for proposed mechanisms and connections between TBI, MS, and DV/IPV.

RESULTS: While no papers met all inclusion criteria, there is a significant epidemiological overlap between populations at risk of DV/IPV-induced TBI and those who develop MS. There is support in the literature for physiological mechanisms of increased intracranial pressure from venous outflow occlusion with strangulation, paired with the activation of astrocytes, degradation of tight junctions and a loss of blood-brain barrier (BBB) integrity seen with TBI. Disruptions of the BBB from central nervous system (CNS) injury proteins, including S100B, MBP, NSE, GFAP, UCHL-1, and NfL, enter the bloodstream and trigger an immune antibody response. Accumulation of TBI-induced proteins is linked to an increased risk of developing neurological diseases. Serum antibody IgG is released as a secondary immune response following IgM, which the injured CNS is unequipped to defend against following TBI-induced BBB degradation. Similar to ischemic brain injury, 24.8% of ischemic stroke patients have shown elevated oligoclonal IgG bands. Elevated levels of IgG have been established as a risk factor for MS. In TBI, the level of IgG has been associated with the severity and frequency of ischemia and TBI.

CONCLUSION: The literature suggests that TBI and venous outflow obstruction from strangulation may lead to inflammation thus activating the immune system and increasing the likelihood of developing the clinical syndrome of multiple sclerosis. This evidence-based theory highlights the probable link between abuse-induced brain injury and the risk of developing MS. Further research is necessary to establish this relationship and begin education, prevention, and care programs.

Incidences of traumatic brain injury (TBI) are responsible for over one million emergency department visits a year, and rehabilitation costs in the United States may well exceed $100,000, depending on the observed population and injury severity (Dismuke et al., 2015). A national inpatient survey found that the majority of TBI-related hospitalizations for urban (99.6%) and rural (80.3%) residents were located at an urban hospital (Daugherty et al., 2022). When comparing health care costs, individuals living in rural areas experience higher costs yet receive fewer services than urban residents (Graves et al., 2018). Additionally, individuals living in rural areas are at risk for poorer outcomes following TBI due to a lack of accessible resources (e.g., hospital care, neurosurgical interventions, and post discharge rehabilitative services) and must often utilize transportation services to travel to their providers (Brown et al., 2019). The disparities between rural and urban post-TBI care and rehabilitative services are a public health issue, and the overall stress due to lack of accessibility and decreased support can lead to further psychological, cognitive, and physical post-concussive symptoms. For the present study, data was collected from a representative and randomized sample of California residents in collaboration with California Department of Rehabilitation’s TBI Advisory Board and The California State Survey Panel, and from individual assessment packets from 2 out of 12 California Association for Traumatic Brain Injury (CATBI) sites in Northern and Southern California who provide services to improve the independent living and community reintegration for survivors of brain injury. The findings indicate that individuals living in rural counties engage in less community participation than those residing in urban counties. These differences can be explained by how accessible outpatient and rehabilitative services are in an individual’s residence. People with TBIs living in rural areas face many barriers as they reintegrate into their community, especially a lack of knowledge about programs and resources. The disparities between rural and urban post-TBI services and community integration can be diminished by increasing access to transportation and information about resources that are available.

INTRODUCTION: While traumatic brain injury (TBI) is a recognized cause of postural orthostatic tachycardia syndrome (POTS), the prevalence of POTS among TBI patients is unknown, and the etiology of POTS following TBI is not well understood. POTS is characterized by orthostatic symptoms including dizziness, lightheadedness, fainting, and near syncope, but is also associated with cognitive dysfunction/attention deficits, sleep issues, headache, and anxiety. This collection of symptoms is attributed to dysfunction of the autonomic nervous system and can be seen in a subset of patients following TBI. Without a Tilt Table Test (TTT), POTS symptoms are often considered post-concussive and/or psychological leaving the underlying medical condition undiagnosed, with potential for increased concussion recovery time and decreased quality of life for TBI patients.

OBJECTIVE: The goal of this retrospective case review is to determine the prevalence of POTS in a series of refractory post-concussion symptom patients, 6 months or more post injury, who were evaluated at a single interdisciplinary TBI and Concussion Clinic.

METHODS: A retrospective chart review of 55 consecutive TBI patients evaluated between October 2022 and November 2023 was conducted. The patient’s gender, mechanism of injury, and symptoms associated with POTS were assessed.

RESULTS: Sixty-five percent (36) had orthostatic issues characteristic of POTS including dizziness, lightheadedness, orthostasis, or near syncope. Additional symptoms often associated with POTS were also observed. Eighty nine percent (49) of patients had cognitive dysfunction/attention selectivity issues, 73% (40) had headaches, 67% (37) had anxiety, 56% (31) had sleep issues, 45% (25) had balance issues. Sixty-one percent of the patients with orthostatic symptoms were female.

CONCLUSION: Symptoms associated with POTS were seen in the majority of patients with refractory post concussive symptoms. These findings suggest that patients with refractory post concussive symptoms should be routinely evaluated for POTS. Conversely, given the correlation between TBI and POTS, patients with POTS should be assessed for signs and symptoms of TBI as many in this demographic may have unrecognized brain injury including sports injuries and abuse induced brain injury/strangulation. Further research is warranted on the intersection of TBI and POTS.

Oculomotor dysfunctions, including convergence and accommodative disorders, are common in up to 80% of patients with acute concussion and 30-40% with chronic concussion. However, convergence and accommodative disorders are not specific to concussion, and they can also be present from development/non-traumatic origin. While there is a high (20-30%) prevalence of oculomotor dysfunctions in the non-concussed clinical pediatric population, prevalence of oculomotor dysfunctions in collegiate athletes is currently unknown, and this imposes strong limits on conclusions that can be drawn from studies of visual and vestibular-oculomotor dysfunction following suspected concussion. This study collected baseline oculomotor data to assess the presence of vergence and accommodative dysfunctions in collegiate varsity athletes with and without a history of concussion.

METHODS: All experimental procedures were IRB approved. Intercollegiate varsity athletes at the University of California, Berkeley were asked to participate in a comprehensive oculomotor assessment. Athletes were asked about their concussion history and were cleared from prior concussions by the team physician prior to baseline testing. All baseline oculomotor examinations were conducted by the same optometrist.

RESULTS: Baseline data were collected on a total of 179 athletes. Athletes were assigned to groups either with (n=63, 17 females, 45 males) or without (n=116, 32 females, 85 males; control group) a history of a diagnosed concussion. Refractive correction of either glasses or contact lenses were worn by 22.9% (n=41) of the sample. Participants reported whether they had received at least one eye examination with an eyecare provider in their lifetime (52.5%; n=94) and whether they had received an eye examination within the last year (35.75%; n=64).

Baseline binary variables (proportions) were compared using Fisher’s exact test, and continuous variables were compared using the non-parametric Wilcoxon rank sum test. There were no statistically significant differences between groups for any of the oculometric measures. Notably, when compared to clinical norms, there were multiple clinically relevant oculomotor dysfunctions at baseline, including abnormal near cover test (11.2%), reduced fusional divergence at near (15.1%), reduced fusional convergence at near (29.1%), reduced near point of convergence (6.2%), reduced near point of accommodation (13.4%), and reduced accommodative facility (20.1%).

CONCLUSION: There were no statistically significant differences between athletes with or without a history of concussion for convergence or accommodative (dys)functions. Athletes exhibited clinically relevant levels of accommodative and vergence dysfunction at baseline, and 47.5% of the sample had never had a comprehensive eye exam in their lifetime. This lack of information regarding baseline oculomotor function in athletes confounds possible baseline abnormalities with those resulting from suspected concussions. This, in turn, can impact their education, sports performance and pull-from-play and return-to-play decisions.

It is unclear whether the assessment position of patients with Disorders of Consciousness (DoC) affects the result of Coma Recovery Scale–Revised (CRS–R). Currently, only the arousal protocol is required to facilitate patients’ engagement and accurate scoring. The study aims to investigate the impact of positioning on the CRS-R total score. This is a retrospective study analyzing a total of 1470 CRS-Rs performed on 232 patients in four different positions, i.e., lying in bed (Bed), sitting at the edge of a mat (Mat), sitting in a wheelchair (Wheelchair), and up in a standing position (Standing), in an acute inpatient rehabilitation setting. A conditional random coefficients multi-level model was used to examine the changes of CRS–R based on the position, accounting for repeated measurements within subjects and the variability introduced by different raters. The cohort contains 65.1% male, age 37.4±16.2, and includes primarily traumatic brain injury (47.0%) and hypoxic-ischemic brain injury (26.7%). Each patient underwent an average of 10.3±6.8 CRS–Rs. The mean CRS–R total score was 7.4±4.1. The average arousal protocol used was 3.0±2.1 per session. We found that the CRS–R total score was significantly associated with the assessment position. Using the Bed as reference (controlling age, gender, etiology, number of arousal protocol used, and days post-injury), patients assessed in the Mat, Wheelchair, and Standing had estimated 1.3-, 1.1-, and 1.5-point increases in the CRS–R total score, respectively (P = 0.002, 0.008, and 0.050; overall, upright vs. lying, 1.2-point increase, P = 0.003). The CRS–R total score was found significantly associated with the number of arousal protocols used. However, it was estimated that with every additional administration of the arousal protocol, the CRS–R total score decreased by 0.8-point (P < 0.001). We further identified that, using the Bed as reference, the number of arousal protocol used was not associated with the assessment position, with and without controlling the abovementioned factors. Our results demonstrated that the increased use of arousal protocols indicated lower arousal level at baseline, thus, poorer CRS–R performance. The increased use of arousal protocols did not serve to improve CRS–R performance. The assessment position appears to be more important. Patients scored significantly higher in an upright position. One point change could potentially make a diagnostic difference in the CRS–R. The finding may be related to generally improved physical and cognitive functionality in an upright body position, rather than to arousal only. The arousal protocol needs to be applied as indicated regardless of the assessment position. In conclusion, CRS–R is better to be performed in an upright position rather than a lying position in patients with DoC.