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

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: TBI (Traumatic Brain Injury) has been noted to be a chronic disease state. Uncertainty over predictors of long-term outcomes causes great distress for individuals with disabilities and their families.

OBJECTIVES: The purpose of this study was to determine the factors involved in the long-term prognosis of cognitive impairments and the long-term prognosis of each cognitive impairment.

METHODS: Long-term prognosis was defined as a state of 5 years or more from injury, and on May 23rd, 2023, we looked through articles from 1990 to May 23rd, 2023. A scoping review of the literature was conducted following the 2018 PRISMA-ScR Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). Exclusion criteria were involving participants under 25 years old, not addressing CVD (Cerebrovascular Disease) and TBI, and no mention of cognitive impairments.

RESULTS: A total of 9 peer-reviewed articles were included for review. Factors involved in the long-term prognosis of cognitive impairment were that the severity of cognitive impairment was related with GOC (Glasgow Outcome Scale) and PTA (Period of Traumatic Amnesia) (n= 2), not related with the pre-injury social environment, but with pre-injury intelligence and educational level (n= 2), that there was significant improvement between 1 and 3 years after injury (n= 7), that there was no difference in cognitive ability after 5 and 10 years, and that some subjects have reduced memory and working memory after 10 to 15 years (n= 2). The 10-year group scored worse on NSI total score and TBI-QOL (Traumatic Brain Injury Quality Of Life) Cognitive Concerns-General, the TBI group had more physical and neurological complaints than the non-TBI group, and the neurocognitive characteristics of participants with fewer symptoms of psychological distress were better. They also stated that the prevalence of impairment of simple attention was low, with the majority of patients not impaired by 5 years post-injury, and that working memory impairment was still present at 5 years but improved between 6 months and 1 year post-injury. Visual perceptual impairment was shown to improve mostly between 1 and 5 years, and the majority of patients were free of impairment at 5 years. The prevalence of executive dysfunction was low, with the majority of participants showing no impairment by 5 years after injury, with significant improvement between 6 months and 5 years.

DISCUSSIONS: Predictors of cognitive impairment due to TBI were prior education level and severity of TBI, with visual perceptual function, attention recovered earlier from onset, and executive function and working memory recovery taking longer. However, the association between symptoms of emotional distress and cognitive function and the fact that TBI patients often have complaints suggest that the possibility that some subjects may experience memory and working memory deficits should be addressed.

INTRODUCTION: Although often classified as ‘mild’ traumatic brain injuries (mTBI), concussions can have serious public health consequences, with approximately 32,000 people experiencing persisting symptoms in Ontario each year. Due to the lack of a standardized care pathway, care quality and receipt depend on social, geographic, and demographic factors. Concussion treatment in Ontario is provided through a combination of public and third party funded care, the nature of which is determined by the cause of injury. Third party funded care is accessible if injured in an insured motor vehicle collision or at the workplace, while those injured by falls typically only receive publicly or self-funded care. As a result, equity deserving groups are disproportionately affected, impacting the level of care received and recovery. There is little health equity-focused research characterizing the concussion population and their healthcare utilization.

OBJECTIVES: To 1) characterize mTBI/concussion and identify inequities related to healthcare utilization, and 2) highlight implications for subpopulations that may be disproportionately impacted.

METHODS: Individuals a formal mTBI/concussion diagnosis between 2016 to 2022 were identified using administrative databases (e.g., Discharge Abstract Database, National Ambulatory Care Reporting System, Ontario Health Insurance Plan, and National Rehabilitation Reporting System). Incidence and healthcare utilization rates (e.g., emergency department (ED) visits) were calculated.

FINDINGS: A total of 1,075,791 cases of mTBI/concussion were identified in Ontario. Of this cohort, nearly 30% of people sustained their injury through a fall, while sport-related injuries and motor vehicle collision comprised just 5% and 3% of all mTBI/concussions respectively. The incidence rate of concussion was 1.5 times higher among those with mental health comorbidities (14.07 vs 9.61 per 1000) and nearly 3 times higher among those with cognitive comorbidities (22.44 vs 7.87 per 1000). The ED visit rate during the two years post-concussion was considerably higher in people aged 65-79 (101 visits per 100 patient years (PY))) and 80+ (139.8 visits per 100 PY) compared to the overall provincial rate (79.3 visits per 100 PY). Those in rural or Northern areas, in the lowest income quintile, with pre-existing cognitive comorbidities, and who sustained their injury by falling also had considerably higher ED visit rates compared to the overall rate. The most utilized healthcare resource among people with concussion in the years following their injury was mental health-related care (95.8 per 100 PY).

CONCLUSION: Concussions occur frequently among older adults and people with mental health or cognitive comorbidities, who are all at greater risk of becoming high users of the healthcare system. Administrative data show that most concussions are caused by falls, which carries important implications, as fall-related injuries are unlikely to be covered by insurance-funded healthcare. Fall prevention efforts should be targeted toward these subgroups to decrease the burden on healthcare systems.

INTRODUCTION: Traumatic brain injury (TBI) is a major public health problem resulting in hospitalizations, morbidity and mortality globally. Despite the large proportion of elderly persons experiencing TBI, limited data exist at the population level.

OBJECTIVE: To apply quality indicators (QI) to examine TBI care quality for older persons (65 years and older).

METHODS: Provincial administrative health services data from publicly funded healthcare were used. We co-developed 12 QIs with healthcare partners and persons with lived experience, and measured care quality for patients 65+ years with TBI between 2016 and 2021. Age and gender adjusted incidence and QIs with 95% confidence limits were calculated. Variations in QI performance was explored according to age group, sex, geographic region, and income quintile.

RESULTS: A total of n=15,194 complex-mild and n=19,237 moderate/severe brain injury cases were identified between 2016-2021. The age and gender adjusted incidence rate for all severities of TBI increased with age. Older persons were more likely to get admitted to general rehab than specialized TBI rehab after discharged from acute care (8.35% vs 3.04% for persons with moderate to severe TBI). Higher ED visits rates in years 1 and 2 increased with age (156.8 per 100 PY in 80+ age group vs. 114.9 per 100 PY in 65-79 years age) group). The rate of falls in the first two years after moderate-severe TBI was higher among elderly patients (43.7 per 100 PY in 80+ age group vs. 30.6 per 100 PY in 65-79 year group).

CONCLUSION: This study establishes a foundation for quality-of-care assessments and monitoring disparity in care for older adults with TBI at a population level. Gaps were identified in receiving rehabilitation services after discharge from acute care, and follow-up with health professionals. Ensuring that older persons receive appropriate rehabilitation and community support to reduce falls is necessary to maintain independence in the community.

INTRODUCTION: Traumatic brain injuries (TBI) are chronic conditions requiring ongoing care. However, the long-term supports needed by people with moderate-severe TBIs are often not in place after inpatient care, despite community living constituting most of their lifetime. This is complicated by the fact that care quality varies tremendously depending on socio-economic and regional factors, often disproportionately affecting equity-deserving groups. Despite these challenges, few jurisdictions have developed care quality evaluation strategies grounded in evidence-based, standardized, and equity-focused care pathways that span the care continuum.

OBJECTIVES: To 1) evaluate TBI care quality and equity within the context of the care pathways approach and 2) use Quality Indicator data to identify system-level gaps and target improvement initiatives.

METHODS: Residents admitted to acute care with a formal TBI diagnosis between 2016 to 2022 were identified using administrative databases (e.g., Discharge Abstract Database, National Ambulatory Care Reporting System, Ontario Health Insurance Plan, and National Rehabilitation Reporting System). From this cohort, data for 13 Quality Indicators were collected to reflect the stages of the TBI care pathway: pre-acute (n=2 indicators), acute (n=1), rehabilitation (n=3), community (n=7).

FINDINGS: A total of 34,431 incident cases of TBI with hospital stay were identified. Over half of the people with TBI in this cohort were older adults (65+), and nearly 70% sustained their injury by falling. Older adults had a substantially higher incidence rate of moderate-severe TBI (39 per 100,000 for 65–79-year-olds and 173 per 100,000 for those aged 80+) than the overall rate (19 per 100,000). People with pre-existing cognitive comorbidities had an incidence rate six times higher than that for people without such comorbidities (161 per 100,000 vs 26 per 100,000). Admission to inpatient rehab was low across the province, with 22% of moderate-severe TBI patients admitted to any inpatient rehab and only 9% admitted to a specialized facility. For older adults, people with cognitive comorbidities, and people in Northern Ontario, specialized inpatient rehab admission was further limited. Of those who did not receive inpatient rehab, 55% were not followed-up by any medical professional in the community within 30 days of acute discharge. Within one year of acute discharge, just 10% were followed-up by a relevant specialist (e.g., physiatrist).

CONCLUSION: Care quality and equity gaps were identified in the rehabilitation and community stages of care. Admission to specialized inpatient rehabilitation was extremely limited, particularly in Northern regions, and for older adults and people with cognitive comorbidities, despite the latter groups being at higher risk of sustaining these injuries. Few people with TBI received timely primary care follow-up in the community. It is imperative to target injury prevention and quality improvement efforts toward these inequities and gaps to enhance TBI care quality, improve long-term outcomes, and optimize recovery.

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.

Brain Injury is the leading cause of death and disability in the UK for people aged 0-40 (Centre for Mental Health “CMH” 2018) and diagnosed in 70% of all cases of head injury (Ponsford, Sloan and Snow 2013). However, there is limited knowledge and understanding about this topic (Norman 2020, Mantell 2017) with very little known about social care and social work with people with brain injury (Holloway 2020) even though, social work plays an important role in the assessment and treatment of people with this condition (Linden et al 2023). The complexity and hidden nature of the condition can lead to misdiagnosis and inappropriate care and support. Safeguarding Adult Reviews repeatedly identify social workers’ poor understanding of ABI as a contributing factor to the premature deaths of people who struggle post-injury. Heads Together is an interdisciplinary effort led by Prof. Andrew Bateman and other brain injury experts and researchers including psychologists, social workers, academics from 5 universities in the UK and experts by experience funded by the NIHR with the aim of addressing this knowledge and skills gap. This unique project has five work packages including a systematic review of existing brain injury social work literature recently accepted for publication. Topic: Social workers’ understanding of acquired brain injury: A systematic review of the current evidence-base. We have surveyed 152 students, 65 social work educators and interviewed newly qualified and experienced social workers and commissioners in the UK to inform outputs. A recent addition to our project is Making Headway, a play in collaboration with local specialist brain injury charities brings the brain injury experience to life and serves as a trans-disciplinary teaching tool for health and social care students and other disciplines.

The play is supported by actor-led, interdisciplinary student workshops shown to over 150 University of Essex students in March, phase two is to tour four universities reaching 600 students by April 2024. Making Headway was presented at a Think Tank at the IBIA World Congress on Brain Injury in Dublin, with members of the team making presentations at this and other conferences including the Joint Universities Social Work Education Conference in Glasgow and has been nominated for a global interprofessional award. The team has influenced policy by contributing to two UK Parliament Post Notes and NICE Guidelines reviews and training social workers in a local authority where a safeguarding adult review into the death of a person with ABI was conducted. Heads Together is developing practice improvement resources including a website and interactive modules which present brain injury in a clear and concise manner and ultimately, improves outcomes for people affected by ABI. The brain injury social work toolkit will be launched during World Social Work Week 2024.

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.

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.

Effective treatment of cognitive impairments after traumatic brain injury (TBI) requires a clear understanding of the neuroanatomic and neurochemical bases of those impairments. Toward that end, this presentation will briefly review the structure and function of cerebral cholinergic systems in the brain and their role in cognition. The short- and long-term effects of TBI on cerebral cholinergic systems in the brain will be presented. That presentation will integrate findings from basic science (e.g., experimental injury studies) and clinical science (e.g., neuroimaging, electrophysiology, cerebrospinal fluid, and neuropathology) studies. Those findings and their translation to clinical studies, including multicenter randomized controlled trials, of medications for persistent cognitive impairments among persons with TBI then will be reviewed. Particular attention will given to the results from and clinical implications of three multicenter randomized clinical trials of acetylcholine-enhancing medications for persistent posttraumatic cognitive impairments. Future directions in this area of clinical neuroscience and lessons learned from studies performed to-date then will be discussed.

Recovery from acquired brain injury was widely thought to be complete at 6 months post-injury in the late 70’s and early 80’s. As survival rates improved for increasingly severe injuries, interest grew in challenging the 6-month recovery presumption. Hospital length of stay often exceeded 12 months and discharge options were limited to skilled nursing homes, psychiatric hospitals, jail, the street or to family homes. The strongest impetus for exploration of further recovery came from the workers compensation insurance sector due to the tremendous lifetime costs associated with care for individuals with ABI. Thus, the postacute community-based rehabilitation sector was born and has evolved over the last 40 years.

Dramatic changes in LOS in IRFs and increased awareness of rehabilitative potential after ABI combined as catalysts for this rehabilitation niche. These changes enabled identification of huge gaps in treatment availability with most patients receiving only minimal treatment due to persistent financial constraints to access.

This session will review the historic development of the field. Clinical and financial outcome efficacy will be reviewed. Limitations identified for postacute community-based rehabilitation will be discussed. Finally, the potential for this level of treatment as both vast and exciting will be presented.

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: Concussions occur inside and outside of the sports realm – including those resulting from falls, motor vehicle crashes, and violence – yet the emerging concussion response and management evidence is predominantly from the sports perspective. The 6th International Conference on Concussion in Sport, held in October 2022, prompted wide-spread updating of concussion training and resources. Notably, assessments for concussion, and the roles of rest and aerobic physical activity supporting recovery, have been considerably refined.

TRAINING: The Concussion Awareness Training Tool (CATT) provides free evidence-based concussion training tailored to diverse audiences, extending beyond medical professionals, coaches, youth, athletes, and their caregivers, to include educators, workers and their employers, and those supporting survivors of intimate partner violence. Recently launched on its new online platform, the CATT offers up-to-date educational eLearning modules and downloadable resources, each created using an integrated knowledge translation approach. CATT resources include the Concussion Pathway (also adapted for the Motion Picture, Film, and Live Performance industry, and for neurodiverse students); questions to ask your doctor; strategies for return to activity, school, school, and work; accommodations during concussion recovery; and considerations for managing mental health symptoms.

REACH: To date, over 175,000 people worldwide have completed CATT training. The cattonline.com website receives over 17,000 visits per month from over 50 countries: primarily Canada and the United States, as well as the United Kingdom, Australia, China, New Zealand, Ireland, India, South Africa, France and elsewhere. This wide-reaching approach to online concussion education, originally launched in 2013, provides information in both English and French. ELearning modules for medical professionals, coaches, and school professionals are also available Arabic. CATT training has been mandated by over 100 sporting associations, universities, schools, and other organizations in Canada and the United States. This includes 32 universities/colleges across Canada, and BC School Sports representing 450 schools in British Columbia. Furthermore, the University of British Columbia is the first medical school in Canada to incorporate concussion education into its curriculum, using the CATT resources.

EXPANSION: Global education efforts using CATT have focused on East Africa (Uganda, Kenya, Tanzania), Pakistan, Japan, Lebanon, and South Africa. CATT is currently seeking engagement with Indigenous partners within Canada to create culturally appropriate concussion resources.

To date, no definitive physical exam has emerged for identifying objective residual dysfunction following mTBI. Because the TBI spectrum involves subtle damage to a diffuse network of neuronal connectivity within the cortex, brainstem, cervical cord, and/or autonomic nervous system, abnormalities cannot always be localized to a focal lesion. Such findings are termed “soft signs,” and may be the only neurologic sequelae from an mTBI. These signs may persist chronically following an injury, latently impacting neurologic function and resilience. However, because the traditional neurologic exam is designed to detect focal lesions, it is often normal in patients affected by mTBI and therefore of limited utility in their diagnosis and management. In the absence of an objective, sensitive examination that assesses soft signs, many clinicians still commonly rely on subjective impressions to identify or exclude mTBI. This leads to diagnostic errors, false expectations about recovery, and limits the effective analysis of treatment interventions. A helpful contribution to this gap in validated assessment methods is the physical and neurologic examination of soft signs (PANESS), which was developed in 1984 as a tool for assessing developmental neurologic conditions in children. The PANESS has been shown to be more accurate at identifying subtle dysfunction after a concussion than the sports concussion assessment tool (SCAT). However, the PANESS does not incorporate newer research on mTBI (e.g., the VOMS), and is not standardized for adults. Considering this, we propose the SME, a soft sign assessment tool that complements the traditional neurologic bedside examination and is specific for concussion/mTBI. It integrates information from medical literature, academic conference presentations, and our research team’s more than 90 years of combined experience evaluating and studying mTBI patients. The SME focuses on identifying visual, motor, balance, and autonomic nervous system soft signs following an mTBI. These selected domains appear to be most vulnerable to damage following craniocervical neurotrauma. This premise is supported by studies on concussed athletes examined with the PANESS, by the work of other authors, and by our own prior and ongoing research evaluating processing speed, reaction time, vision, and hip flexor strength in mTBI patients. An abbreviated subset of the SME (the aSME) has recently shown effectiveness in capturing neurologic changes in subconcussed boxers compared to age-matched swimmers, post-activity. Our clinical experience and ongoing quantitative studies support the validity of the SME as a soft sign exam with the promise of being an effective tool for assessing and monitoring impairments acquired after neurotrauma. Our goal is to continue refining the SME to make it a standardized tool, available to all clinicians who evaluate and treat this complex patient population. Such an exam is necessary to improve diagnostic accuracy, guide treatment interventions, evaluate their efficacy, and assist in outcome prediction.

A subconcussive impact is defined as a bump, blow, or jolt to the head that does not manifest any overt clinical symptoms. Such events carry a latent potential for neurological impairment, and thus should be of particular concern in contact sports. Existing assessments for sports-related concussions (SRC) predominantly focus on explicit, self-reported symptoms and more obvious neurological impairments, leaving subtle neurological signs in athletes largely undetected and inadequately assessed. These subtle neurological findings are termed soft signs and represent non-localizing abnormalities within the central nervous system. Growing research illustrates that repetitive subconcussive impacts can lead to consequential neurological outcomes and may ultimately culminate in chronic traumatic encephalopathy (CTE). One study demonstrated acute vestibular dysfunction in female soccer players following a single heading practice. Another study demonstrated white matter changes on diffusion tensor imaging in the brains of high school football players post-season, despite no formal concussion diagnoses. Moreover, multiple studies have shown that athletes deemed clinically recovered from SRC are at increased risk for further injuries; our prior research revealed soft signs of residual neurologic damage in such post-concussed athletes. These findings indicate that the existing SRC evaluations lack sensitivity in identifying residual neurological impairments. The Spokane mTBI Exam (SME) was previously developed by our group as a tool to identify soft signs following mTBI/concussion. In the present study, we used an abbreviated version of the SME (aSME) to screen 19 male amateur boxers, compared to 9 non-contact male athletes, swimmers. Participants ages 9 to 22 were evaluated pre- and post-activity using the following metrics: near point convergence (NPC), saccades, ocular smooth pursuits, vestibular-ocular reflex, finger-to-nose testing (dysmetria), and hip flexor strength. Findings revealed that 14 of 19 assessed boxers exhibited post-activity deterioration in their aSME evaluations, and 10 of these 14 exhibited worsening in multiple metrics. Loss of hip flexor strength, deterioration of NPC, and dysmetria, in that order, were the most common changes noted in the boxers. Two out of 9 swimmers revealed a post-activity deficit in 2 of these metrics, which normalized on repeat testing. In contrast, boxers who exhibited a post-activity deficit in NPC either stayed the same or worsened on repeat testing. The post-activity decreases in hip flexor strength observed in boxers cannot be attributed solely to fatigue because swimmers, following a comparable duration and intensity of exercise, showed either stable or improved hip flexor strength. Our findings substantiate the aSME as a pivotal tool for bolstering diagnostic sensitivity in detecting and tracking subconcussive trauma. By objectively monitoring neurological soft signs, the aSME fosters a refined and targeted approach to post-traumatic assessments, which may be used to guide informed return-to-play decisions in contact sports and potentially pave the way for tailored rehabilitation strategies.

This hands-on session will explore compensatory and remedial interventions for improving functional vision after acquired brain injury with an emphasis on increasing spatial awareness as the foundation. Interventions explored will apply to rehabilitation for people with mild, moderate, and severe brain injury across the continuum of care and will be of interest to an interdisciplinary audience.

INTRODUCTION: Research into the dysfunction of the postural control system in humans has been inconclusive as to the rehabilitative role of the oculomotor subsystem. Studies on the relationship between pursuit and saccadic activities in the rehabilitation of postural abnormalities have had conflicting findings regarding the predictable role of oculomotor activities in rehabilitation. Most studies are performed on healthy athletes rather than challenging compromised patients in a clinical setting. The aim of this study was to measure computerized posturography and saccadic latency of a subject population with loss of postural control to include migraine headaches (39.3%), post-concussion syndrome / traumatic brain injury (35.7%), vertigo (17.9%), and other brain disorders (7.1%) as primary diagnoses.

METHODS: A matched pairs design (pre- and post-treatment assessments) was used to assess the efficacy of a course of personalized Cortical Integrative Therapy, as the rehabilitative strategy. Postural control of 28 refractory adult patients, aged 18 to 64, was measured by computerized posturography and saccadic latency by videonystagmography. As head movements challenge the subject by generating a vestibular stimulus in addition to that generated by the subject’s sway, computerized posturography was conducted with the head in neutral position, right and left. Posturography scores in the three testing positions were compared to right and left horizontally directed saccades latency. These measurements were taken over the intervention course (mean = 7.66 weeks, range 0.57 to 20.29 weeks).

RESULTS: Efficacy of the personalized Cortical Integrative Therapy was indicated by a near 25% (P < 0.05) improvement in the posturography value. Post-intervention, the average latency values with the head in the neutral position and the head in left rotation demonstrated a negative linear correlation (P ≤ 0.05) in both directions of saccadic activity. In contrast, right head rotation testing yielded no statistically significant correlation between latency and posturography values. As expected, no correlation was observed between the postural stability and oculomotor function at baseline pretreatment testing.

CONCLUSION: The relationship between saccadic activities in the rehabilitation of postural abnormalities was demonstrated in a heterogeneous subject population with varied brain injuries and brain-based disorders. Moreover, computerized posturography data suggests that head rotation can help direct therapeutic strategy. Altogether these data suggest a rehabilitative role of vestibular postural systems in conjunction with oculomotor systems, which beckons development and implementation of new intervention approaches for broad-based clinical practice.

This interactive pre-conference course will offer a multidisciplinary approach to best practices in neurobehavioral assessment of patients with disorders of consciousness (DoC). Course faculty will include multidisciplinary experts on DoC clinical care and research (representing occupational therapy, physical therapy, neuropsychology, and neuroscience). This course will focus on optimizing behavioral assessment utilizing evidence-based standardized methods to establish diagnosis and prognosis. We will also review common confounding factors that may mask consciousness. Neurobehavioral assessments across various settings (e.g., acute/intensive care and post-acute) will be included. This course provides learners with hands-on demonstrations and will guide attendees through practice administration of some assessments. There will also be opportunities for discussion with experts. Case studies will promote active learning through presentation of varied patient neurobehavioral profiles. Attendees will be exposed to the most recent evidence related to assessment of the DoC population and evolving approaches to conceptualizing the measurement of consciousness.

The past two decades have seen an impressive expansion of literature on the diagnosis, prognosis, and pathophysiology of severe traumatic brain injury (TBI). Rigorous investigations have uncovered the value of standardized bedside assessment, utility of advanced neurotechnologies, and the potential for recovery in even the most severely injured patients. Along the way, we have learned lessons related to the complexity of data acquisition, analysis, and interpretation in this unique patient population. This session will present key findings on assessing level of function and outcome in patients with acute and chronic severe TBI as well as strategies that new studies are implementing to address the limitations of prior research.

Will prognosis after severe traumatic brain injury ever be as precise as in other conditions? Should life-sustaining therapy be prolonged for all patients with acute disorders of consciousness? How do we know that intensive inpatient rehabilitation improves outcome after severe brain injury? Do you have a question about severe brain injury that you have always wanted to ask, but never been in the right environment and with the right people to do so? In this unique session, the audience gets a chance to pose the most challenging and controversial questions to a multidisciplinary panel of severe brain injury experts who will have just a few minutes to respond. Spanning clinical and research expertise ranging from neurocritical care to neurorehabilitation, the audience will hear from physicians and neuropsychologists who have devoted their careers to improving the lives of individuals with severe brain injury.

In disease management, it is imperative to identify the right level and intensity of services one needs to be able to assign who can be managed with self-management versus disease management or case management. Social determinants of health be an important risk factor that may help target services appropriately. PRAPARE is a social determinants of health measurement tool. The BeHEALTHY investigators recently completed a scoping review of the PRAPARE tool which will be presented. Lastly, the investigators examine data from the Veteran’s Administration to learn about the outcomes of service members with TBI receiving primary care and specialized brain injury care.

In this session, data will be presented regarding complex associations between military-related traumatic brain injury (TBI), mental health conditions, and suicide risk. Drawing upon a life course perspective, the sessions will explore how cumulative disadvantage theory sheds light on brain health challenges faced by Veterans returning from Iraq and Afghanistan. The central question addressed is whether military-related TBI is linked to an increased incidence of new-onset mental health conditions and suicide risk.

There is a major unmet need for evidence-based approached to cognitive performance optimization following TBI and other brain injuries. Relevant therapeutic domains include behavioral (e.g., sleep, diet, physical exercise, alcohol, caffeine), pharmacological (e.g., stimulants, nootropics), brain stimulation (e.g. transcranial magnetic stimulation, transcranial direct current stimulation, transcranial alternative current stimulation), brain training (e.g., occupational therapy, speech therapy, computer-based brain training), and management of medical comorbidities (e.g., sleep apnea, chronic pain, diabetes, hypothyroidism, anemia, vitamin deficiency). This session will provide an overview of the field, and focus in depth on a few key areas: sleep optimization, appropriate use of methylphenidate, arousal, and physical exercise.

After “mild” traumatic brain injury/concussion in civilians and military service members, the severity of depressive symptoms is among the strongest correlates of overall outcomes. We and others have shown that people with substantial depressive symptoms after TBI have different brain functional connectivity patterns on resting state fMRI than people with major depressive disorder or TBI without substantial depressive symptoms. In this session, we will introduce individual subject resting state fMRI brain functional connectivity mapping, and then describe the use of this mapping technique to guide transcranial magnetic stimulation treatment. Pilot clinical trial results will be presented, along with an update on our ongoing multicenter double blinded randomized controlled trial.

Objective: Provide an overview of the current state of knowledge on factors related to relationship quality and stability following stroke.

Data Sources: Cumulative Index to Nursing and Allied Health, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched on November 15, 2022, for literature on factors associated with (1) relationship quality and (2) relationship stability after stroke.

Study Selection: English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability after stroke were included. Three reviewers independently assessed eligibility. Consensus meetings were held in case of divergent opinions. Forty-four studies were included.

Data Extraction: Information regarding study objectives and characteristics, participant demographics, independent and dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross-Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer. Identified factors are described and presented according to the domains of the International Classification of Functioning, Disability, and Health model.

Data Synthesis: Thirty-seven factors related to relationship quality after stroke were identified, covering the domains of body functions and structures (e.g., cognitive problems), activities (e.g., decrease of physical intimacy), participation (e.g., being socially active), environment (e.g., medication side effects), and personal factors (e.g., hyper-vigilance). Eight factors related to relationship stability were identified, covering the domains of participation (agreement on reciprocal roles) and personal factors (e.g., quality of pre-stroke relationship).

Conclusions: Relationship quality and stability after stroke are related to a multitude of factors. Future research should confirm the relevance of factors found in few studies of suboptimal quality, explore possible associations between relationship stability and factors falling in the domains of body functions & structure, activity, and environmental factors, and explicitly explore potential positive effects of stroke on relationships.

Traumatic brain injury (TBI) affects millions of individuals annually, resulting in reduced quality of life in patients and substantial financial costs. TBI impacts learning and memory functionality and is a recognized risk factor for the development of Alzheimer’s disease (AD). A key component of the immune response in TBI and AD is activation of the inflammasome. The inflammasome is a multi-protein complex that activates pro-inflammatory cytokines interleukin (IL)-1β and IL-18, through the recruitment of caspase-1 and apoptosis-associated speck-like protein containing a caspase recruitment domain (ASC). Activation results in pyroptotic cell death through cleavage and formation of the GSDM-D pore. We have previously demonstrated that genetic predisposition to AD, utilizing the 3XTg mouse model, significantly exacerbates inflammasome activation in the acute injury phase of TBI and leads to greater cognitive impairment. Furthermore, we showed that inhibition of the inflammasome through use of an anti-ASC therapeutic monoclonal antibody (IC100), was effective in reducing inflammasome activated IL-1β in 3xTg mice after TBI. Our current work investigates the chronic inflammatory response of TBI pathology in familial AD. 5-month-old wild-type (WT) and 3xTg (AD) mice underwent either sham surgery or moderate controlled cortical impact (CCI). At 3-months after surgery, animals were sacrificed and the ipsilateral cortex was dissected, homogenized, and immunoblotted for inflammasome proteins and IL-1β. A Simple Plex assay was completed using cortical lysates to assess neurodegeneration and astroglia reactivity by probing for neurofilament-light (NfL) and glial fibrillary acidic protein (GFAP), respectively. Histology and immunohistochemistry was also conducted on whole brain sections blotted for ASC, NfL, and GFAP. Sections were used to assess cortical and hippocampal tissue loss after injury using volumetric analysis. Our results demonstrate that IL-1β protein remains significantly elevated in the chronic stages after injury in AD animals compared to WT. We also observed a persistent elevation of the inflammasome proteins NLRP3, caspase-8, and ASC in injured AD mice which was not present in injured WT animals. Moreover, there is a chronic increase in NfL expression after TBI, with evidence of ASC co-localization after injury. Interestingly, only injured AD mice demonstrated continued elevation of GFAP. GFAP+ cells additionally demonstrated ASC co-localization in the injured AD mice. Finally, there was a significant loss in total cortical volume and total hippocampal volume in injured AD mice compared to the injured WT mice. In conclusion, we provide evidence that genetic predisposition to AD leads to chronic inflammasome activation and pro-inflammatory cytokine release after TBI leading to even greater neurodegeneration. Importantly, our results indicate that the inflammasome could be a promising therapeutic target for TBI with AD.

BACKGROUND: This presentation describes the knowledge translation approach that the Model Systems Knowledge Translation Center (MSKTC) and Traumatic Brain Injury Model System (TBIMS) researchers take to develop and disseminate user-friendly print and video resources to promote rehabilitation outcomes for people living traumatic brain injury (TBI). TBIMS centers provide clinical care and conduct research to improve the lives of people with TBI. The MSKTC supports TBIMS centers to conduct knowledge translation activities, identifies health information needs, and develops and disseminates information resources based on Model Systems research and available evidence. The MSKTC also collaborates with the Spinal Cord Injury Model System and Burn Injury Model System Programs to conduct similar knowledge translation activities. Both the MSKTC and the TBIMS are funded by the National Institute on Disability, Independent Living, and Rehabilitation Research, U.S. Department of Health and Human Services.

METHODS: Knowledge translation is “the exchange, synthesis and ethically-sound application of knowledge—within a complex system of interactions among researchers and users—to accelerate the capture of the benefits of research” (Canadian Institutes of Health Research, n.d.). To maximize the impact of research and development activities to improve the lives of patients and families, it is important to engage stakeholders throughout the entire process (Barwick, Dubrowski, & Petrecca, 2020; Bowen, Botting, Graham, & Huebner, 2016; Nguyen et al., 2020; Parry, Salsberg & Macauley, 2015). The MSKTC collaborates with the TBIMS researchers to apply knowledge translation strategies and engage TBI survivors and their family members to develop, test, and disseminate free research-based resources.

OUTCOMES: The MSKTC has worked with the TBI model system researchers to develop resources on over 30 rehabilitation topics in multiple user-friendly formats such as factsheets, infocomics, videos, narrated slides, and podcasts. A MSKTC user feedback survey showed that 90.8% of the participants strongly agreed or agreed that MSKTC factsheets directly “apply to me or someone I know;” and 87.3% rated MSKTC factsheet quality as good or excellent. Between January 1, 2012 to October 31, 2023, over 5 million people from over 203 countries consumed the TBI contents on the MSKTC.org website. The MSKTC.org has been the go-to place for high quality rehabilitation resources for people living with TBI in the US and across the globe.

CONCLUSION: Knowledge translation can be an effective framework to help researchers better understand the needs of patients with TBI and families and develop strategies to meet their needs and improve their rehabilitation outcomes.

In this presentation, the speaker will review strategies to promote cooperation and understanding between medical and educational teams. Various models of care including national demonstration programs that highlight the collaboration between medical and educational providers will also be discussed.

Measuring cognitive difficulties post-concussion is challenging. ‘Baseline’ testing paradigms have individuals complete neurocognitive tests before a concussion occurs (e.g., pre-season for an athlete), followed by post-injury testing for comparative purposes. Evidence suggests that this is effective, but is not always feasible. The second, ostensibly more common method, is to compare an individual’s post-concussion neurocognitive test scores to published norms. The purpose of this project was to examine the utility of neurocognitive testing to screen for cognitive impairment following concussion in a general adult population, using two study designs. Study 1 involved 343 adults (17-85 years of age) seen within seven days of concussion. Subjective cognitive difficulties were characterized by the Sport Concussion Assessment Tool (SCAT) scores for the four cognitive items. Objective neurocognitive measures included Trails A & B and Symbol Search & Coding (administered at Weeks 1, 2, and 12 post-injury), and a measure of verbal learning and recall and Digit Span (Weeks 2 and 12). Scores placing at or below the 3rd percentile on any measure were classified as ‘impaired’. 174 (50.7%) participants reported ‘mild’ cognitive SCAT symptoms; 124 (36.2%) as ‘moderate’; 45 (13.1%) as ‘severe’. Between 1-26 participants (0.3-7.6%) were classified as ‘impaired’, depending on the neurocognitive measure used. Those with severe subjective cognitive difficulties had lower neurocognitive test scores compared to the other groups, however they were still within the ‘average’ range using normative data. Determining an objective indicator of cognitive impairment related to subjective difficulties using a norms-based approach was not established. Study 2 employed a case-control design using 30 adults with acute concussion and 30, non-concussed control participants. A preliminary analysis of 29 non-concussed controls (median age: 24 [IQR 23-28] years, 20 females (67%), average years of education: 16.4 [SD: 1.4]) and 12 age, sex, and education-matched individuals with concussion (median age: 26 [IQR 24-30] years, 11 (92%) females, average years of education: 16.0 [SD: 2.8]), completed the same neurocognitive measures at Weeks 1, 2, and 8 post-injury. Preliminary analyses showed there were few measures with significant differences between cohorts at any single assessment (Coding Week 1, p=0.047; Delayed Recall Week 8, p=0.028). However, the non-concussed cohort improved significantly on several tests over time where the concussed cohort did not (i.e., Learning Week 1 to 8, non-concussed p=0.002, concussed p=0.134), suggesting an absence of learning effect in the concussed cohort. Full dataset to be presented at the conference. Without a baseline approach, using test norms to qualify and quantify a person’s subjective cognitive symptoms may yield false negative results. Therefore, more specific normative data (i.e., adjusting for learning effects) is needed to accurately evaluate cognitive performance post-concussion. Without this, the clinical focus should be to provide treatment and education for any specific self-reported symptoms.

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

Purpose:
Recovery times for collegiate athletes with sport-related concussion (SRC) range from 2 to 4 weeks. The stimulated blink reflex is abnormal after SRC. This study assessed the blink reflex daily from initial assessment (within 2 days of injury) to recovery and compared it with symptom recovery.

Methods:
Prospective cohort. Blink reflex (EyeStat) and Post-Concussion Symptom Scale (max=126) were assessed daily from injury to recovery. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion). Associations over time were assessed using regression.

Results:
41 SRC (from 36 unique athletes, 20.46±1.50 y/o, 79.5% male, 0.95±1.2 days since injury) are included in analysis. Mean symptom severity at initial assessment was 25.00±17.3 and mean time to symptom resolution was 10.87±7.3 days. No significant correlation over time (i.e. p-value of interaction term of blink reflex parameter with days since injury) was observed between daily symptom severity and differential latency (p=0.097), initial velocity (p=0.150), time to open (p=0.506) and number of oscillations (p=0.228). However, a significant association was found for latency (p=0.016), time to close (p=0.017) and excursion (p=0.012). In all three of these regression models, symptom severity significantly decreased over time (p=0.013, 0.017 and 0.013, respectively) and correlated with individual blink reflex parameters throughout the recovery period (p=0.002, <0.001 and <0.001, respectively).

Conclusion:
Certain stimulated blink reflex parameters (latency, time to close and excursions) have a significant association with daily symptom reporting over time, meaning that they are abnormal when athletes report a high number of symptoms and return to baseline when athletes are asymptomatic.

Significance:
Identifying patterns on how the blink reflex changes throughout recovery and identifying those that are associated with symptom recovery can help develop algorithms that can use change in blink reflex parameters to predict symptom recovery.

Objectives: Brain-Derived Neurotrophic Factor (BDNF) mediates the neuronal response to injury. It has been hypothesized that BDNF is a potential biomarker of sport-related concussion (SRC). BDNF expression is exercise-dependent, and aerobic exercise is a standard treatment for SRC. This study assessed salivary BDNF expression in athletes with acute SRC and throughout a 2-week aerobic exercise intervention.

Methods: Athletes with acute SRC (n= 32, 66% male, 15.6 ± 1.4 yrs) and healthy controls (n= 28, 66% male, 16.0 ± 1.6 yrs) provided saliva samples weekly (Day 0, 7 and 14). Concussed and control participants were randomly prescribed individualized aerobic exercise at high (5 days/week for 30 minutes) or low volumes (3 days/week for 20 minutes). Prescribed exercise intensity was based on the results from each participant’s graded exercise test. Participants completed standard clinical examinations and symptom reports during each visit. An optimized Enzyme-Linked Immunosorbent Assay (ELISA) for BDNF (R&D systems) was used to assess samples in triplicate.

Results: ELISA standard curves were high quality (healthy r2= 1.00, concussed r2= 0.98). At the initial visit, concussed females had higher salivary BDNF than healthy participants (p=0.002). There was no difference between concussed and healthy males’ BDNF at the initial visit (p=0.627). Over time, concussed females consistently showed higher salivary BDNF expression than healthy females, whereas males were not different. BDNF level was not affected by the volume of exercise participants completed (p=0.767) or by history of prior concussions (p=0.85).

Conclusion: The data suggest that salivary BDNF may be assessed for post-concussion monitoring in adolescent athletes but may be more informative for females. Unexpectedly, exercise volume did not affect BDNF, suggesting that a longer exercise intervention would be required to impact BDNF expression. BDNF levels were not affected by time, regardless of recovery, consistent with reports that physiological dysfunction persists beyond clinical recovery from SRC. In conclusion, salivary BDNF offers a non-invasive and convenient analyte that may aid in concussion diagnosis and for monitoring post-concussion treatment response. However, further research is needed to understand the effects of sex, exercise, and recovery on salivary BDNF after SRC.

Acknowledgment: Support for this project by the Clinical Translational Science Institute at the University at Buffalo (UL1TR001412).

Purpose:
Athletes with sport-related concussion (SRC) have blink reflex abnormalities, and can report combinations of physical, cognitive, fatigue or mood-related symptoms after injury. This study compares blink reflex before and after injury and identifies associations with self-reported symptoms.

Methods:
Blink reflex (EyeStat, BlinkCNS) and Post-Concussion Symptom Scale (max=126) were assessed preseason and within 2 days of SRC. Clustering identified High (HS) and Low (LS) symptom groups. Blink reflex parameters: time to ipsilateral blink (latency), contralateral blink (differential latency), initial velocity, time to open, time to close, number of oscillations, and distance traveled (excursion).

Results:
Differential latency increased (baseline: 4.28±1.8 vs post-injury: 5.33±3.0 ms, p=0.047) and time to close decreased (34.30±5.6 vs 32.38±4.3 ms, p=0.022) after injury on paired t-test, and there was a trend for significance for latency (p=0.094) and oscillations (p=0.074). HS (n=15, 87% male, 20.8±1.5 years, symptoms=43.3±11.4) had slower initial velocity (4.23±0.7 vs 5.16±1.0 pixel/s, p=0.002) than LS (n=23, 74% male, 20.1±1.4 years, symptoms=13.0±6.3), and there was a trend for significance for excursions (p=0.081). Physical symptoms correlated with latency (rho=-0.28, p=0.026) and oscillations (rho=0.37,p=0.003); cognitive correlated with initial velocity (rho=-0.36, p=0.003) and exclusions (rho=-0.38,p=0.002); fatigue correlated with initial velocity (rho=-0.48, p<0.001), time to close (rho=-0.26, p=0.034) and excursion (rho=-0.49, p<0.001). Mood correlated with differential latency (rho=0.49, p<0.001) and initial velocity (rho=-0.30, p=0.014).

Conclusion:
The stimulated blink reflex is abnormal acutely after SRC. Increase in differential latency is suggestive that the contralateral blink reflex arch is less efficient. Decreased time to close with a trend that latency is also faster is suggestive that the blink reflex is excited. The strongest correlations were between increasing differential latency and increasing mood symptoms and decreasing excursions and increasing fatigue.

Significance:
The corneal blink reflex is a primitive brainstem response initiated by light, touch or sound. Technology-assisted objective assessment using a portable blink reflexometer has the potential to aid in SRC diagnosis and validate self-reported symptoms.

Traumatic Brain Injuries (TBI) have been described as the "signature injury" from the Iraq and Afghanistan wars due to the high prevalence of blast exposure. In 2007, the Veterans Health Administration (VHA) implemented a national clinical guideline that required that providers screen all Veterans who served in combat operations for TBI. Then if a Veteran has a positive TBI screen, a TBI specialist should perform a comprehensive TBI evaluation (CTBIE) to determine a diagnosis and develop an individualized treatment plan. However, due to shortages in TBI specialists, some VA facilities were not able to complete CTBIEs for Veterans who screened positive.

To fill this gap, in 2016, VA Hudson Valley (HV) TBI care provider Dr. Cho reached out to a VA facility in Hawaii that needed assistance. To allow VA HV to provide virtual care for their Veterans, they developed a Telehealth Service Agreement (TSA). Using a modality called Clinical Video Telehealth (CVT), Veterans could go to the closest VA facility in Hawaii and connect virtually with a provider in HV, New York to complete a CTBIE. After providing successful gap coverage and a warm handoff to a newly hired TBI provider at the site in Hawaii, Dr. Cho used the framework to partner with other VA facilities who needed support providing TBI specialty care for their Veterans.

In 2021, VA HV was awarded funding from the VA Office of Rural Health which allowed them to form a more comprehensive Tele TBI Program - consisting of three TBI providers, two speech therapists, one psychologist and a TBI coordinator. To reduce patient drive times, reduce COVID-19 exposure, and improve access to care, the team also rolled out a new virtual care modality that allowed Veterans to connect with providers in HV from their personal devices.

To date, the program has provided TBI virtual care consults to over 1,400 Veterans at 20 VA facilities across the US and is working on expanding care to Active Duty Service Members (ADSM) at a Department of Defense site.

Since November 2022, 12% of HV Tele-TBI patients (169) were surveyed using a ten-question patient satisfaction survey. On average, patient satisfaction total scores were 4.7 out of 5.0. Of the 169 patients surveyed, 98% reported that they “felt comfortable discussing medical issues with their provider during the Telehealth visit,” 95% “would recommend tele-health to others,” and 98% said “overall, they were satisfied with the telehealth visit.”

Orthostatic intolerance, a dysautonomia, has been seen to occur in patients after TBI. In this session, we will cover the characteristics of autonomic dysfunction after concussion. We will also discuss diagnostic evaluation and management/treatment approaches for patients who have post-concussive dysautonomia. We will use case-based approach to highlight challenges that we have experienced in our multidisciplinary pediatric dysautonomia clinic.

In this session, we will discuss the differences in evaluation and management of concussion in female patients. We will begin by covering preclinical studies showing sex differences in pathology and behavior after TBII. We will at diagnostic differences focusing on biases in reporting and approaches. We will then look at differences in outcome. We will also discuss other disparities that exist in the approach to concussion. We will conclude with strategies on how to improve our diagnostic and treatment approaches to best fit the patient.

Traumatic brain injury (TBI) exposures and poor health and functional outcomes are well established, particularly in the context of traumatic stressors common among those with histories of military deployments. Our team is advancing precision medicine approaches to predicting longitudinal outcomes through largescale, multi-study data harmonization and machine learning analytics. We combined data from the two largest mild TBI (mTBI) longitudinal cohort studies: The Long-Term Impact of Military-Relevant Brain Injury Consortium Chronic Effects of Neurotrauma Consortium (LIMBIC) Prospective Longitudinal Study (PLS) is a 10-year, 17-site cohort of more than 2,800 combat exposed service members and veterans. The Translational Research Center for TBI and Stress Disorders (TRACTS) is a VA RR&D National Center for TBI research including a 15-year, 2-site longitudinal cohort study of more than 950 combat exposed veterans. This proof-of-concept, precision medicine approach to mTBI longitudinal outcome research includes: 1) defining standardization methods and creating a crosswalk for the modalities and domains of LIMBIC and TRACTS longitudinal cohorts to create a unified assessment profile; 2) identifying a rigorous harmonization approach to allow for overall data analyses using the unified data set; 3) developing a multi-modal, analytic approach for the harmonized data sets; 4) pilot testing the use of a VA-supported machine-learning approach to identify multimodal patterns relevant to predicting long-term posttraumatic brain health; 5) establishing a program of research to analyze the prospective, longitudinal dataset and enable identification of risk factors associated with brain disorders and recovery; and, 6) developing, pilot testing, and proposing follow-up “FAIR” (Findable, Accessible, Interoperable, Reusable) data methods to apply the systems developed in this proposal to incorporate additional relevant, largescale, longitudinal veteran/military data (e.g., Million Veteran Project, VA Electronic Health Record Corporate Data Warehouse) to this robust data resource. We will present harmonized biomarker, imaging, functional, and mental health meta-data, outcomes, and methods designed to be scalable and publicly accessible to further advance precision medicine analytics for TBI.

INTRODUCTION: Existing literature is clear that multidisciplinary treatment of persistent mTBI (concussion) symptoms is critical in improving patient outcomes. Institutions are often left to their own devices to determine how to provide this type of care in a way that is viable for providers, maximizes interdisciplinary potential, and is most helpful to patients and families. This study illustrates one model of achieving interdisciplinary care for a patient population with complex, varied, and persistent symptoms following remote mTBI. An interdisciplinary care model involving Medicine, Nursing, Neuropsychology, and Pediatric Psychology is presented using a case series to illustrate common symptom presentation, in-clinic assessment methods, and treatment recommendations. Twelve months of preliminary descriptive data is presented in this abstract, with five years of analysis available by date of presentation. Considerations related to equity, diversity, and inclusion within this population will be discussed.

METHODS: Retrospective chart review was conducted of patients experiencing persistent symptoms > six months following an mTBI who were evaluated in a pediatric mTBI multidisciplinary clinic. Patients with findings on neuroimaging were excluded. Three cases with persistent symptoms are illustrated. The interdisciplinary care model is presented with an emphasis on each discipline’s role, assessment methods, and treatment recommendations.

RESULTS: Preliminary data extraction of cases over the course of 12 months was reviewed (n = 23). The mean age of patients was 15.8 years (range: 10-21 years). Patients were primarily female (65.2%; sex assigned at birth), White (73.9%), and not Hispanic (65.2%). Mean time since injury was 22.3 months (range 6-72 months). Most common presenting symptoms included mood-related concerns (83%), headaches (78%), and cognitive complaints (65%). The majority of patients (91%) were fully cleared from a mTBI perspective following the interdisciplinary team evaluation. Mental health support was recommended for 96% of patients and 35% were referred to physical therapy. Analysis including a total of five years of data will be reviewed.

DISCUSSION: An interdisciplinary care model provides specialty evaluation and treatment across physical, cognitive, and emotional domains of functioning while decreasing overall medical utilization rates, reducing the potential for conflicting recommendations among providers, and lessening time away from school and work for patients and their families. Most importantly, interdisciplinary management provides a comprehensive treatment plan, making the path to recovery clear and achievable. It also allows for a broader focus on factors predictive of recovery, which may fall outside the scope of a single-discipline visit.

BACKGROUND: Chronic pain is a remarkably frequent outcome of mild TBI (mTBI). Common syndromes include headache, backache, limb pain and prolonged pain in the context of other injuries. Chronic pain after TBI leads to personal suffering, suboptimal functional recovery and increases exposure to opioids. Recent human and laboratory data suggest that dysfunctional endogenous pain control circuits, particularly those centered in the brainstem, may contribute to these pain problems. We hypothesized that descending pain modulatory circuits and aberrant serotonergic signaling are involved.

METHODS: To address the effects of mTBI on descending pain modulation, both rat lateral fluid percussion and mouse closed head models were employed. Pain-related changes were measured using tests of mechanical allodynia in the facial region and hindlimbs. The bright light stress model of headache was used as were injury models including hindpaw incision and tibial fracture. Pharmacologic tools involved systemic, intrathecal and stereotactically targeted injections of selective adrenergic and serotonergic agents as well as neurotoxins such as dermorphin-saporin to eliminate cells expressing mu-opioid receptor. To control the activity of the locus coeruleus and periaqueductal gray matter, virally encoded Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) were administered. Finally, running wheel equipped enclosures were used to study the effects of exercise on endogenous pain control systems after TBI.

RESULTS: We observed that TBI leads to an acute but transient period of pain sensitization characterized by facial and hindlimb allodynia supported by descending signaling through spinal 5-HT3 receptors. After recovery from this sensitization, however, the mice and rats showed profound disruption and plasticity of descending noradrenergic and serotonergic circuits. Maintenance of normal pain thresholds after TBI required the activity of endogenous opioid signaling. In this chronic setting, treatment of the mice or rats with serotonin selective reuptake inhibitors (SSRIs) was effective in restoring endogenous pain control systems and in reducing sensitization after limb injuries. Augmenting descending pain modulation through DREADD stimulation in the locus coeruleus or periaqueductal gray matter provided analgesia in the TBI animals. Finally, exercise beginning days after TBI could restore normal endogenous pain control systems.

CONCLUSIONS: Even mild TBI leads to a state of profound and long-lasting disruption of endogenous pain control systems. Pain control centers in the brainstem are central to this phenomenon. The augmentation of serotonergic signaling using clinically available SSRI drugs or exercise seem to be viable options for the restoration of normal endogenous pain control, and translational studies are indicated.

This section of the course will focus on current opportunities to promote walking and balance recovery after acquired brain injury. Novel technologies including overground and treadmill-based exoskeletons, virtual reality, and functional electrical stimulation will be reviewed along with case study presentation of clinical application along the severity spectrum from disorders of consciousness (DOC) to community integration. The clinical practice guideline to guide locomotor training after brain injury will be discussed along with the challenges and opportunities associated with integration. A review of recommended outcome measures to assess progress and safety will be addressed throughout the severity spectrum. Experiential learning will be facilitated in lab-based sessions with advanced technologies.

This presentation will review research supporting the conclusion that brain injury is a chronic, yet dynamic, condition.

BACKGROUND: Functional Neurologic Disorder (FND), or conversion disorder, is a psychiatric disorder that has no organic basis with symptoms affecting sensory and motor function which are not consistent with known neurologic disorder or other medical diseases. Currently, the understanding of FND is largely limited and evolving. This retrospective study will increase the knowledge of how FND impacts the patient’s dysfunction in mobility and outcome of rehabilitation using Wee FIM scores.

METHOD: There were total of 36 (26 females,10 males) patients who were admitted from 2016-2022. (n=1) in 2016, (n=4) in 2017, (n=2) in 2018, (n=4) in 2019, (n=12) in 2020, (n=9) in 2021, (n=4) in 2022. Patient admitted should have a formal diagnosis by a provider from the referring facility with caregiver’s acceptance of an FND diagnosis. Patients received Wee FIM scores on functional mobility on admission and discharge. Scores were compared from admission to discharge. Patients received therapies from a multidisciplinary team; medical, nursing, physical, occupational, child life, recreational, psychology, and psychiatry. Therapies were evaluated according to their individual needs and discussed weekly during the family meeting. Their length of stay was dependent on their daily progress and patient/family cooperation.

RESULTS: Wee FIM admission scores; Unable to walk; 1 is total assistance TA (44%). 2 is maximum assistance Max A (22.2%). 3 is moderate assistance Mod A (0%). 4 is minimal contact Min A (8.3%), 5 is supervision S (8.3%). 6 is modified independence Mod I (13.8%) and (2.7 %) was 7 for Total independence (TI). Unable to negotiate stairs; TA (75%), Max A (2.7%), Mod A (0%), Min A (2.7%), Needs supervision (5.5%), Mod I (13.8%), TI (0%). Transfers from bed to chair/chair to bed; TA (8.3%), Max A (5.5%), Mod A (8.3%), Min A (5.5%), supervision (22.2%), Mod I (41.6%), TI (8.3%). Discharge scores; (2.7%) was unable to walk, a decrease from 44%. Max A, Mod A, Min A were (0%), supervision (5.5%), Mod I (52.7%), patients who walked and TI (38.8%) an increase from (2.7%). Negotiating stairs; TA (2.7%), Max A, Mod A, Min A were (0%), supervision (5.5%), Mod I (55.5%) up from 41.6%, and 7 (36.1%) significantly improved from (8.3%). For transfer: none needed assistance or supervision, (50%) each for Mod I, increased from 13.8% and TI definitely up from (0%). Length of stay were from 1 day to 44 days.

CONCLUSION: FND can be very debilitating that needs a multidisciplinary team in a rehabilitation facility to improve the patient’s functional mobility. Treatment includes: management of anxiety, depression, cognitive behavior, family, physical and occupational therapies.

Case Diagnosis
A 16-year old girl with a history of asthma, diagnosed with Wernicke-Korsakoff Syndrome following a sleeve gastrectomy.

Case Description or Program Description
The patient presented to the emergency department with acute onset generalized weakness 3 months after a cosmetic sleeve gastrectomy in Mexico. She did not undergo pre-operative screening or education. Post-operatively, she reported vomiting and poor oral intake. She took Biotin, B12, and iron supplements but received no follow up. Neurologic exam revealed nystagmus, and labs showed thiamine deficiency. MRI demonstrated hyperintensities involving bilateral medial thalami, the periaqueductal grey, and bilateral mammillary bodies, consistent with Wernicke’s Encephalopathy. She completed a course of intravenous thiamine and was transferred to acute inpatient rehabilitation on oral supplementation.

Setting
Acute Inpatient Rehabilitation

Assessment/Results
The patient showed inattention, poor motivation, and short-term memory deficits during therapy. She was diagnosed with Wernicke-Korsakoff Syndrome on neuropsychological assessment. During her rehabilitation course, she made significant improvements in strength and activities of daily living. However, she had persistent cognitive deficits that limited her progress.

Discussion (relevance)
Wernicke’s encephalopathy is an uncommon complication of gastric sleeve procedures, developing within 6 months due to thiamine deficiency. Although B12 absorption in the small intestine is preserved, patients may develop thiamine deficiency through vomiting and poor oral intake. Typical symptoms include ataxia, nystagmus, and diplopia. Many patients make a full recovery following thiamine supplementation. Here, we describe a progression from Wernicke’s Encephalopathy to Wernicke Korsakoff syndrome in the setting of poor follow up. Therapy interventions were beneficial for the patient. However, she suffered long term impairment.

Conclusions
Wernicke Korsakoff Syndrome is a permanent neurological condition that can significantly impair quality of life and functional status. With new guidelines recommending bariatric surgeries at an earlier age, it is important to ensure adequate follow up and education on nutritional supplementation and to recognize the symptoms of thiamine deficiency post-operatively.

Clinical guideline recommendations for pediatric post-concussion care and management have undergone major updates in 2023. The Living Guideline team includes 48 concussion clinical experts, researchers, and individuals with lived experience from across the US and Canada. This team collaborates on the Living Guideline for Pediatric Concussion Care (PedsConcussion) project to review new evidence and update the 80+ clinical recommendations, clinical algorithms, return-to-sport/activity, and return-to-learn/school concussion protocols as the evidence evolves. The best evidence from 2023 was collated and assessed, and new critical papers were shared in a living evidence map (EPPIreviewer). A quorum of 88% or more of the 48 experts voted on each update and consensus at 97-100% agreement was attained for all updates that were implemented. Significant updates to guideline recommendations involve revisions to the steps of the return-to-sport and activity protocol, highlighting the benefits of aerobic exercise in concussion treatment. Activities that pose no risk of sustaining a second concussion should be gradually resumed after 1-2 days even if mild symptoms are present. These symptoms may worsen mildly during activity as tolerated. Definitions of relative rest, mild to moderate intensity aerobic exercise, and mild symptom exacerbation have been harmonized with the Amsterdam International Consensus Statement on Concussion in Sport. Additionally, updates have been made to the timing of medical clearance and the definitions associated with it. The new return-to-school protocol reinforces the importance of promptly resuming school activities that do not have a risk of falling or being hit on the head, as tolerated, with the provision for academic accommodations if needed. It also emphasizes that the return to non-contact and low-risk school activities should not be restricted if the individual is effectively tolerating cognitive activities. The importance of restricting screen time in the early stage of recovery is now supported by strengthened evidence. Any activity with a risk of head impact or falling must still be entirely avoided until reassessment and medical clearance are obtained. All patients with a diagnosed concussion are recommended to return for a repeat medical assessment 7-10 days after the initial diagnosis and patients should be referred to specialized care with an interdisciplinary concussion team if post-concussion symptoms do not resolve by 2-4 weeks. Youth at increased risk of prolonged recovery require immediate referral. For more detailed information, including consensus voting details and complete recommendations, the pedsconcussion.com website serves as a valuable resource. Dissemination and implementation of these updates is essential to continue to improve outcomes for all pediatric patients with concussion. The collective efforts of the Living Guideline team highlight a commitment to continually advancing and improving pediatric post-concussion care practices.

Movement disorders are commonly seen clinical phenomena in patients who have suffered a moderate to severe acquired brain injury (ABI). While spasticity and ataxia are well known neurological deficits, less common types of movement disorders are encountered in our inpatient rehab program, which is the focus of this study. Early diagnosis and identification of contributing factors is key to reaching favorable functional outcomes for those patients. Here we present 6 types of clinical conditions including: (1) Parkinsonism with the etiology of ABI versus medication adverse effects. Dopamine agonists and anticholinergic agents may be beneficial for the former while discontinuation of culprit medications is important for the latter; (2) Dystonia with a similar etiology and pharmacological management as parkinsonism; (3) Tardive dyskinesia commonly seen as an adverse effect of dopamine antagonists, for which management is more challenging; (4) Tremor mimicking the symptoms of essential tremor (ET) seen after an injury to the cerebellum or brain stem, for which primidone is usually effective while some other antiepileptic drugs may worsen symptoms; (5) Palatal myoclonus seen after an injury involving the dentato-rubro-olivary pathway, for which antiepileptic medications can be trialed to alleviate symptoms; (6) Chronic post-hypoxic myoclonus which may be well managed with antiepileptic agents such as valproic acid, clonazepam and levetiracetam. We are a multidisciplinary team that specializes in adult ABI rehabilitation. Our team is comprised of physician specialists and allied health professionals including but not limited to pharmacists, physiotherapists, occupational therapists, speech-language pathologists and rehab therapists. We also have ready access to consulting specialists to assist in differential diagnosis and management planning if needed. In addition to medications, non-pharmacological interventions are essential to successfully enhance the function of ABI patients with movement disorders. Allied health teams can assist with positioning, developing strategies and utilizing assistive devices for more controlled movement, and thus creating opportunities to practice. The impact of the above-mentioned neurological conditions on functional movement patterns is assessed throughout the medication trials as the side effects of various medications can take time to develop. Multidisciplinary rehabilitation requires close collaboration among all team members to determine appropriate and effective strategies that, when implemented together, will optimize physical, communication, swallowing, and cognitive function. Continuous collaboration between allied health team members and the medical team is imperative to determine appropriate and effective pharmacological interventions (i.e. to address/manage tremor, hypertonia, movement initiation, etc.) that, in combination with evidence based therapeutic interventions, will enhance and maximize recovery for each patient experiencing movement disorders secondary to ABI.

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: Traumatic brain injury (TBI) is the leading cause of death and disability for the pediatric population worldwide. With concussions comprising the majority of these TBIs, concussions among children and youth are an established public health concern. However, the management of pediatric concussions, particularly the decision to return to school and activity following concussion, is often inconsistent and a one-size-fits-all approach. To (1) individualize concussion management to each patient’s unique recovery, (2) provide guidance and monitoring for optimal rehabilitation, and (3) revolutionize concussion management in the digital age, the Back2Play App was developed based on CanChild’s evidence-based management strategies and the expertise of pediatric, psychology, and rehabilitation clinicians, machine learning engineers, and exercise science specialists. The purpose of this randomized controlled trial was to evaluate whether the App supports safe and symptom-free return to school and activity.

METHODS: Eligible children and youth aged 10-18 were randomized into an App Group and Usual Care Group. Usual Care Group participants completed a symptom survey once daily, and received typical care which usually includes generic guidelines provided by their physicians. App Group participants received an Apple watch with the Back2Play App that provided interactive feedback and monitored real-time biological variables including heart rate and movement; completed a symptom survey thrice daily; and followed CanChild’s evidence-based management strategies. All participants completed two follow-up interviews to assess recovery progress and ascertain if re-injury occurred.

RESULTS: Preliminary results indicate that at follow-up, 78.7% (37/47) of App Group participants had returned to sports, compared to 59.6% (28/47) of Usual Care Group participants (p = 0.074). At the early stages of the Return to School protocol (RTS Stage 1), the mean self-assessed cognitive scale score that measures cognitive activity was greater in the App Group than in the Usual Care Group (2.70 +/- 0.27 [N=53] vs. 2.01 +/- 0.21 [N=45], p < 0.01; error = 95% CI).

DISCUSSION: Recruitment for Phase 3 of this study is nearing completion, with 130 participants of the 160 target recruited. Although not statistically significant, the number of participants having returned to sports at follow-up was greater in the App Group than in the Usual Care Group, potentially indicating a higher likelihood of returning to normal activities. The mean cognitive scale score was also higher in the App Group compared to the Usual Care Group at the earliest RTS stage, suggesting higher cognitive activity at the early stages of recovery in line with CanChild’s management strategies.

CONCLUSION: Results from this study can inform clinicians of the efficacy of app-based interventions within this population and address the dearth of consistency and personalization in concussion management, ultimately enabling children and youth who have experienced a concussion to return to school and activity safer and sooner.

Biomarkers have been fundamental to progress is many fields of medicine, and the paucity of biomarkers of traumatic brain injury are a barrier to progress in the field. Recently, several analytical assays for proteins found in blood have been cleared for use by the US Food and Drug Administration and the European Commission as adjuncts in the assessment of TBI, and others are in the horizon. This session will review the state of the science of TBI biomarkers, discuss current barriers to further adoption, and highlight contexts-of-use where biomarkers are anticipated to impact brain injury medicine.

Evidence accumulated over the past decade have led to recognition that, for many patients, traumatic brain injury (TBI) continues to evolve after the acute period and initial recovery. Multiple rigorous epidemiologic studies indicate that there is a modest increase in risk late life dementia and cognitive impairment in individuals who sustain a TBI in early and mid-life. Despite the substantial societal burden imposed by the long-term neurodegeneration after TBI, very little is known about the pathophysiology involved, there are no biomarkers that are prognostic for identifying individuals at risk for progressive neurodegeneration, and no effective therapies to prevent or slow this process. This session will review the newest epidemiological data, discuss new insights from neuroimaging and biomarker studies, and examine practical strategies that can be applied clinically.

In this session, we will discuss the 2018 United States and 2020 European Guidelines regarding the optimal clinical management of patients with severe traumatic brain injury and disorders of consciousness. We will consider the emerging role of advanced neurotechnologies, such as task-based functional MRI and EEG, in the diagnostic and prognostic assessment. We will also discuss current best practices for pharmacologic therapy to promote recovery of consciousness.

The Curing Coma Campaign was launched in 2019 to improve management and outcomes for patients with disorders of consciousness. Since its launch, numerous scientific initiatives have advanced the state-of-the-science in the field of disorders of consciousness and have established a roadmap for how to improve future clinical care for this population. In this session, we will discuss the scientific and clinical contributions of the Curing Coma Campaign, and how they helping to elucidate the neurobiology of impaired consciousness and its recovery.

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.

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.

INTRODUCTION: Acquired brain injury (ABI) is associated with financial capability challenges. This includes challenges with financial-related social interactions and remembering financial cues or behavioral strategies. In a previous focus-group study, people living with ABI discussed an individualized financial wallet-card as a novel intervention idea.

PURPOSE: To develop and explore the feasibility, acceptability, uses, and outcomes related to the use of an individualized financial wallet-card for adults living with ABI.

METHODS: We used a longitudinal qualitative intervention design. We recruited 10 adult participants who live with ABI (70% female; 1 to 59 years post-ABI). We co-designed a two-sided wallet card with each participant: one side addressed how others can better help the participant in social financial-related situations, and the other side addressed personal financial reminders or strategies. After co-designing their card, we interviewed participants and sent them copies of their cards in printed/laminated and electronic versions. Participants then completed up to five more interviews about their cards over 15 weeks. Participants had the opportunity to update their cards at the final interview. We analyzed longitudinal interviews and wallet-card content using content analysis.

RESULTS: Participants reported using the printed/laminated card more than the electronic version. There were many similarities across participants’ cards, with almost all participants including information related to living with invisible disabilities. Multiple participants reported the importance of card individualization. Common social cues included were to ask others to provide them time, speak slower, or provide written information. Common personal financial reminders were to focus on their needs before their wants, take time or talk with a trusted other person before making financial decisions, or make and check a monthly spending plan. Most participants reported the card very helpful to addressing some of their financial capability challenges. More reported the social situations side to be more helpful, especially to get the help they needed, with many reporting using the card beyond finance-related social situations. Multiple participants noted the personal financial reminders helped to keep them accountable and make better financial decisions. Two participants noted other people expressing negative attitudes about the card, although this was from family members and not from general community members. Some participants reported not using the card much or forgetting to use the card; for two participants, this tended to be in familiar environments where people knew them well.

CONCLUSION: The co-designed financial wallet-card is a potential low-cost technology to address some of the financial capability challenges experienced by some adults living with ABI. It was beneficial and helpful to many participants. Individualization of cards was important, as some people had unique contexts. Future improvements to the card would be to improve the official look of the card and increase the efficiency in card production.

OBJECTIVES: Functional neurological disorder (FND) denotes neurological disorders of unknown origin that are not explained by other mental or medical disorders or structural injury to the brain. Symptoms can include motor/sensory loss, seizures, tremors, and other disturbances that affect critical areas of functioning. Traumatic brain injury (TBI) can be a precipitant, along with trauma and Post Traumatic Stress Disorder (PTSD) – both of which may serve as either predisposing or precipitating factors for FND. The prevalence rate of FND is higher among active-duty service members than the U.S. civilian population, with those presenting with a history of mood or PTSD symptoms at greater risk. Emergent findings on clinical treatment integrating cognitive, mindfulness, and compassion-based approaches for FND are promising but limited. There is no current evidence on body-oriented, somatic therapies which may holistically address the range of symptoms causing distress and/or dysfunction for adults with FND.

METHODS: A 3-week course of integrative treatment was delivered to a 33-yr old Special Operations Forces, male service member presenting with FND, TBI, PTSD, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, insomnia (clinically significant, in severe range), and chronic pain. The service member received 1-hour psychotherapy sessions, 3 to 4 times per week during an intensive post-acute inpatient brain injury rehabilitation program. Treatment consisted of a somatic and embodiment-based approach integrating cognitive behavioral psychotherapy for PTSD and chronic pain, psychoeducation, body-oriented interventions, mindful movement, meditation, self-compassion exercises, and homework. Repeated measures analyses examined change in pre-post outcomes on the General Anxiety Disorder-7, Patient Health Questionnaire-9, PTSD Checklist for DSM-5, Insomnia Severity Index, Neurobehavioral Symptom Inventory, and Self-Efficacy for Symptom Management Scale.

RESULTS: At post-intervention, there were significant decreases in neurobehavioral symptoms (31 points), PTSD (10 points), anxiety (5 points), and depression (11 points). A significant increase in self-efficacy was also found (30 points). There was a non-significant downward trend in insomnia severity (3 points). Feasibility and acceptability were established.

CONCLUSIONS: To our knowledge, this is the first evidence of efficacy, feasibility, and acceptability of third-wave cognitive behavioral treatment with a military service-member, as well as the first evidence for any integrated psychotherapy approach for adults addressing FND, TBI, and PTSD concurrently. Further adding to the literature, this is also the first investigation to demonstrate support for the effectiveness of an embodiment-focused, somatic approach to FND recovery. Further investigations based on experimental designs are needed to expand upon these preliminary findings. Recommendations for future studies and trauma-sensitive, somatic, and compassion-based approaches in intensive rehabilitation of FND and comorbid TBI and PTSD are provided.

Vestibular and oculomotor deficits are common after concussion and can contribute to many post -concussive symptoms, impairments, and functional limitations. These may include dizziness, balance problems, blurred vision, headaches, nausea, light sensitivity, sound sensitivity, difficulty reading, difficulty concentrating, anxiety, and fatigue. New guidelines recently published from the International Conference on Concussion in Sport-Amsterdam, indicate the benefits of vestibular rehabilitation in individuals with dizziness, neck pain, and/or headaches which persist for more than 10 days in adults, and 4 weeks in children and adolescents. Participants will describe common vestibular-oculomotor symptoms post-concussion and identify evidence-based assessments and treatment approaches.

Individuals experiencing persistent post concussive symptoms often report visual changes as well as changes in sensory processing. This session discusses the current recommended practice for assessment and intervention of visual and sensory symptoms as they relate to functional independence. Participants will be able to define the role of occupational therapy and identify its role in the management of these symptoms and be able to identify both assessment and basic treatment techniques to apply to both visual and sensory deficits.

Objectives
Examine the effect of whiplash associated disorders (WAD) on concussion outcomes among adults evaluated within 7 days of injury.

Setting
The study was carried out at the Hull-Ellis Concussion and Research Clinic (Toronto Rehabilitation Institute, Canada).

Methods
The authors analyzed patient’s clinical charts and routinely collected data from individuals that were admitted to the clinic between July 2019 and March 2020 from one-week to eight-weeks post-injury. The presence of WAD was determined by the presence of neck pain and cervical spine tenderness or restricted range of motion on physical examination by a clinic physician. Patients’ characteristics and outcomes were described according to the presence or absence of concomitant whiplash associated disorders (WAD).

Results
82 medical files were reviewed retrospectively. 19 cases were excluded due to missing data and 63 cases were included in the study. 25 (40%) patients included were deemed to have a concurrent WAD. The WAD group presented with higher symptom severity (mean of 59/132 (SD 32) versus 39/132 (SD 26) for the no WAD group) and number of symptoms (mean of 18/22 (SD 5) versus 15/22 (SD 6) for the no WAD group) on the SCAT5 on initial assessment. By the end of the follow-up (eight weeks post-injury), fewer individuals with WAD had recovered from their concussion than those without WAD (44% with WAD versus 66% without WAD).

Conclusion
Our findings show that the combination of both concussion and neck symptoms can result in an overall greater frequency and intensity of initial symptoms, and a longer duration is required for recovery of all injury-related symptoms. Recognition of cervical injury in tandem with a diagnosed concussion soon after injury may facilitate earlier referral to appropriate rehabilitation.

This presentation will detail challenges in securing needed rehabilitation services for people with acquired brain injury. Factors impeding access will be reviewed, including but not limited to compliance with the three hour rule, financial disincentives and denial of coverage.