The BATL is an extensively validated and widely used semi-structured clinical interview designed to diagnose traumatic brain injury (TBI) across the lifespan in post-9/11 military veterans with particular attention to blast-related injury. The BATL uses a forensic approach designed to differentiate clinical symptoms of TBI (e.g., altered mental status, posttraumatic amnesia, loss of consciousness) from other common physiological and psychological reactions to head injury and trauma. The BATL has been updated to: (1) incorporate the most up-to-date TBI diagnostic criteria (American Congress of Rehabilitation Medicine [ACRM] 2023; Veterans Affairs [VA]/Department of Defense [DoD] Clinical Practice Guidelines); (2) assess for subconcussive repetitive head injury risk from blast and blunt force trauma; and (3) offer a flexible battery approach to allow clinicians and researchers to select modules specifically tailored to high-risk TBI contexts (e.g., military, civilian, intimate partner violence, and sports). These changes will expand the breadth of context in which the BATL can be utilized and reduce time burden for administering the BATL interview based on research and clinical goals. Prevalence of injury using the BATL-2 will be presented for a large cohort of U.S. Veterans from the Translational Research Center for TBI and Stress Disorders (TRACTS), a 15-year, 2-site VA Rehabilitation Research and Development National Center for TBI Research. The sample consists of 878 combat exposed post-9/11 Veterans, 90% male, 71% Non-Hispanic White, with mean age of 35 (SD = 9.2) and mean education level of 14 years (SD = 2.2). On average, they served in 1.68 tours (SD = 1.1) for 16 months (SD = 11.2) and completed the BATL interview 70 months (SD = 52.0) after returning from their last deployment. TBI was highly prevalent, as 74% (n = 645) sustained a TBI in their lifetime and 54% (n = 474) sustained a TBI during military service. Additionally, 32% (n = 284) of Veterans sustained a blast force military TBI, while 33% (n = 290) sustained a blunt force military TBI. Data on subconcussive blast and blunt exposure were collected in a subset of 228 of these veterans, revealing that 60% (n = 137) reported exposure to subconcussive blast events and 43% (n = 99) reported exposure to subconcussive blunt force trauma. Results of an initial psychometric evaluation of BATL-2 scores in 2 samples of military veterans will be presented. Overall, results indicate that the BATL-2 is a psychometrically sound measure of both ACRM 2023 and VA/DoD TBI diagnosis and symptom severity. Importantly, the BATL-2 strongly corresponds with the BATL-1, suggesting the BATL-2 provides continuity in evidence-based assessment of TBI with the transition to ACRM 2023 criteria.

BACKGROUND: A growing body of literature has demonstrated that aerobic exercise (AE) can be beneficial in improving outcomes from concussion. This evidence resulted in an update to recent consensus guidelines for the treatment of sport-related concussion, which recommend initiating light AE within two days of injury. Most research has focused on athletes recovering from sport-related concussion. Less is known about the principles of AE following non-sport-related concussion. The goal of this pilot study was to examine the efficacy of various methods to inform AE recommendations post-concussion in a general adult population.

METHODS: This pilot study represents a subset of the Toronto Concussion Study population. Participants were eligible for pilot study inclusion if they were 18-45 years of age and at low-risk for underlying cardiac disease (determined by the treating physician). Participants who were either uninterested or ineligible were followed regularly by the clinic physician (“Usual Care” cohort). Eligible participants were randomly assigned to either the “Exercise Testing (ET) plus Usual Care” cohort, or the “Exercise Testing (ET) plus Individualized Prescription” cohort. All randomized participants completed a Buffalo Concussion Treadmill Test (BCTT) within seven days of injury. The “ET plus Usual Care” cohort received usual care AE recommendations, while the “ET plus Individualized Prescription” cohort received an individualized prescription based on their BCTT performance. Participants enrolled in both “ET” cohorts were provided with a heart rate (HR) monitor to wear during all waking hours, until they were deemed to be recovered from their concussion by a clinic physician. Kaplan-Meier survival analyses were conducted to evaluate for differences in time to recovery between each of the study cohorts. Log rank tests were used to compare the survival curves for all analyses.

RESULTS: 75 participants were included in this analysis (average age: 31.2 years [SD 11.4], 65.7% female). 20 participants were eligible and randomized to either the “ET plus Usual Care” cohort, or the “ET plus Individualized Prescription” cohort (10 per arm). There was an observed longer time (restricted mean survival time [RMST]) to recovery of the “Usual Care” cohort (n=55, 7.2 weeks) compared to the combined “ET” cohorts (n=20, 5.7 weeks, p=0.046). However, there was no significant difference in time to recovery between the “ET plus Usual Care” cohort (n=10, 6.2 weeks) and the “ET plus Individualized Prescription” cohort (n=10, 5.0 weeks, p=0.350). There was no significant difference in minutes spent above certain HR thresholds (50-90% of age-predicted max HR) between the two “ET” cohorts (p=0.295-0.968).

CONCLUSION: Normalization of AE early post-concussion, under supervision, appears to improve recovery time post-concussion. Individualized AE prescription did not improve outcomes nor did it alter activity levels in our sample. Future rigorous studies should further examine the role of supervised AE in the acute phase post-concussion.

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

Evidence indicates that “brain health” can reduce cognitive decline and promote healthy aging. It is thought that optimizing brain health may be particularly important in the years following brain injury. A Lifestyle Medicine approach promotes brain health through its 6 pillars: plant-based nutrition, physical activity, stress management, avoidance of risky substances, restorative sleep and social connections. This approach has been successfully applied to persons living with stroke through the PAVING the Path to Wellness Program. Details about this program and its potential application to chronic brain injury will be presented.

Cognitive-communication disturbance following traumatic brain injury has historically been well characterized, along with recommendations for assessment and treatment. Approaches often focus on underlying disorders of attention, memory, and executive functioning and their impact on communication behaviors, especially in the chronic stages of recovery. However, another cognitive domain, core language, is often overlooked, and recommendations for the acute stage of neuro-rehabilitation are lacking, leaving clinicians in the inpatient rehabilitation setting at a loss for what to do. This session will review findings from a 3-year study investigating acute post-traumatic language disturbance (aPTLD) in an inpatient neuro-rehabilitation setting. Incidence of naming disturbance as determined by the Boston Naming Test, characterization of aPTLD relative to aphasia types, and evolution of aPTLD from admission to discharge will be presented.

BACKGROUND: The quality and quantity of evidence varies widely across different aspects of Moderate to Severe Traumatic Brain Injury (MSTBI) Rehabilitation research. There is a notable lack of published research evidence to inform evidence-based recommendations. This is especially prominent in the new and emerging areas of rehabilitation, such as Telehealth and Intimacy and Sexuality. The Canadian Clinical Practice Guideline for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury addresses this gap following a robust living update process that consists of ongoing identification of research literature, expert panel review, rigorous evaluation of evidence quality and achieving clinical consensus in consultation with persons with lived experience (PWLE) to develop and modify current evidence-based recommendations in the areas that lack published research.

METHODS: A rigorous multi-component guideline review process was developed and refined to ensure that recommendations reflect the rapidly emerging evidence and address the priorities identified by end users and people with lived experience.

1) Systematic review of published MSTBI evidence
2) Priorities identified by PWLE of MSTBI and guideline end users through surveys and focus groups
3) Diverse interdisciplinary expert panels that include PWLE
4) Online and offline review of the current published evidence, clinical and lived experience
5) Rigorous grading of available evidence
6) Expert panel voting to achieve a minimum of 75% by 80% of the expert panel

RESULTS: Since 2015, this review process has yielded 351 recommendations divided into 21 chapters focusing on different domains of MSTBI rehabilitation. Currently, the Guideline includes 239 Consensus-based recommendations which comprise 68% of the Guideline. Two new sections were added in 2022/23: Telerehabilitation - 14 recommendations including 11 (79%) consensus-based and Intimacy and Sexuality - 10 recommendations including 9 (90%) consensus-based. Recommendations were added that responded to PWLE comments that the guideline did not stress the importance of continuing rehabilitation into the community through participation in daily activities and promoting hope for ongoing improvements. Focus has also been on developing algorithms and tools to facilitate implementation.

CONCLUSIONS: This comprehensive TBI rehabilitation guideline uses a transparent and methodologically robust review process that integrates knowledge and experience of diverse interdisciplinary expert panels including the people with lived experience of MSTBI. This process allows the development of high-quality recommendations in the priority areas where published evidence is currently lacking. Including consensus-based recommendations and tools helps ensure that the guideline contains all relevant, current and critically evaluated recommendations that integrate the new areas of rehabilitation and incorporate the needs, values and preferences of PWLE.

Background: The Canadian Clinical Practice Guideline (CPG) for the Rehabilitation of Adults with Moderate to Severe Traumatic Brain Injury (TBI) helps inform TBI care across jurisdictions through its ongoing and comprehensive review of research and clinical evidence. This review helps the CPG produce best-practice recommendations to improve the quality and consistency of care provided by healthcare professionals, as well as patient health outcomes. The CPG’s beneficial effects, however, are contingent on not only a methodologically rigorous guideline development process, but also on the successful knowledge translation (KT) and implementation of the resulting recommendations and associated tools.

Objectives: Orient healthcare professionals to the CPG and help 1) increase understanding of the clinical value and utility of the living CPG and Ideal Care Pathways, which promote quality care and equity of access across the care continuum, and 2) guide implementation of the up-to-date best-practice recommendations, resources, and clinical tools.

Methods: Regulated Health Professional Associations in Ontario, Canada were approached to partner in and co-develop targeted KT activities rooted in the principles of adult learning: 1) self-concept; evidenced in CPG KT’s self-directed, asynchronous learning model, 2) adult learner experience, readiness to learn, orientation to learning, and motivation to learn; evidenced in CPG KT’s target audience and voluntary attendance, and 3) active learning; evidenced in CPG KT’s real-life case examples presented by healthcare professionals and interactive discussion. The KT activities promoted the relevance of the CPG by using clinical data, partnering with relevant practicing clinicians, and addressing current clinical issues in TBI care. The primary target audience was healthcare professionals who may not routinely encounter individuals who have sustained a TBI, and/or who may not be up to date on TBI best care practices.

Results: The most popular KT method was interactive webinars, but in many cases, multiple methods, including newsletter articles, blog posts, website links and all-member emails, were used. All webinars were recorded, and their slide decks were made available for asynchronous learning. The KT activities have been ongoing since June 2023, and have shown excellent engagement as evidenced in the increasing number of visits to the CPG website, with 7700 visits in July 2023 to 9205 visits in September 2023. Invitations have been forth coming to return for further interactive sessions and to present at relevant RHP conferences. Further data on the CPG KT engagement, follow-up activities, and Google Analytics for the online resources will be presented.

Conclusion: Our multi-faceted and collaborative KT strategy for the CPG and Ideal Care Pathways is key in helping healthcare professionals make informed TBI clinical care decisions based on the most up-to-date scientific evidence for quality care, supporting the overall vision to provide ideal and equitable lifelong care for ALL after a brain injury.

Introduction: Traumatic Brain Injury is the leading global cause of disability. In Canada alone, 2% of the population lives with a TBI and many survivors require significant ongoing support and rehabilitation post injury in order to return to functional independence and achieve meaningful goals. In recent years, holistic treatment for TBI has become an increasingly popular approach to provide the brain with the best possible environment to heal. Some key lifestyle modalities, which may support a recovering brain, include nutrition, exercise, mindfulness, cognitive activity, good sleep and limiting harmful exposure. Although some of these interventions have evidence for supporting rehabilitation post TBI, the effects of combining these modalities into a larger program have not yet been studied. Furthermore, vital allied health care services needed to provide well-rounded care are costly for most individuals and persons who are members of traditionally marginalized groups are overrepresented in the population who do not have access to this type of care. Consequently, many patients are left untreated and lost to follow-up after their acute injury has been addressed and stabilized. This in turn leads to a tremendous burden on our healthcare system, as we know earlier and intensive treatment post TBI is important to mitigate long term disability.

Objective: To pilot a novel primary care clinical model designed to address gaps in TBI care and provide effective, equitable access to care,

Methods: The novel primary care model was developed through review of published evidence for key lifestyle modalities, which are the cornerstones of holistic care: nutrition, exercise, mindfulness, cognitive activity, good sleep and limiting harmful exposure. The model was refined through consultation persons with lived experience and clinicians to ensure feasibility and relevance to address current gaps in care. The model was piloted utilizing government funded regulated health professionals using a Family Health Team framework to promote continuity of care following discharge from acute care facilities.

Results: A structured model of care was developed that included quality indicators to assess process, outcome and acceptability of care. This care model is consistent with the Ideal Care Pathways that is currently being implemented In Ontario. All patients referred to the care team were included in the pilot, regardless of severity of injury and personal circumstances. All had access to community based rehabilitative care with medical oversight that otherwise would not have been available to them. Patients reported high satisfaction with the model of care and the progress towards their identified goals.

Conclusion: This pilot represents an example of how holistic Family Health Team care can be effectively and efficiently provided in the community to support patients’ goals of living meaningful lives after brain injury.

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

Objective: to describe the process and outcomes of implementation projects addressing key elements of the TBI Care Pathways.

Methods: Provincial Working Groups composed of over 200 people with lived experience (PWLE) and their families, clinicians, healthcare administrators, community service providers, policymakers and researchers met to identify crucial components that constitute ideal care, highlighted system-level gaps, and developed and prioritized companion quality indicators by ranking them on significance and feasibility. Groups set regional and provincial implementation priorities. We identified regional teams to champion the implementation of three projects. Each team received a grant to co-design with persons with lived experience and their families a care map and implementation manual related to the implementation priorities. The projects had to implement an ongoing sustainability plan and evaluation strategies and ground their work in the principles of implementation science.

Results: A set of implementation priorities was established which included two common priorities across the province: education for persons with lived experience and their families, and care coordination and navigation. Out of 6 pilot implementation projects, three involve TBI Care Pathways; these include: 1) a large urban concussion care clinic partnering with the TBI system navigator to optimize referral services; 2) a justice-involved support organization and a TBI system navigator creating a resource list for those living with complex needs, and 3) a community base provider facilitating post-traumatic stress disorder training after TBI. Each group developed the requisite care map, implementation manual, sustainability plan and collected evaluation data specific to their project. The teams presented their work at a provincial summit attended by PWLE and their families, clinical managers, system planners, injury-specific navigators, and funded and government officials to discuss opportunities for scale and spread.

Conclusion: These evidence-based Ideal Care Pathways represent a road map for quality improvement with a strong emphasis on community care and transitions. The implementation projects are initial steps of the journey towards ensuring that all persons living with TBI and their families receive equitable care and supports to address their chronic needs over the lifespan.

Background: Neuroinflammation is an important feature of traumatic brain injury (TBI). However, the biological markers of TBI and their connections with cognitive, affective, and physical symptoms remain poorly understood, particularly in the 3-12-month time-period post-injury. Thus, the objective of our study was to examine the relationships between symptoms, biomarkers of neuroinflammation, and functional outcomes in TBI patients 3-12 months post-injury.

Methods: A cross-sectional study of 39 TBI patients was performed at a South Florida TBI clinic between May 2022 and June 2023. All patients were between 3-12 months post-injury during study participation. Clinical data, including initial Glasgow Coma Scale (GCS) score, pharmacological information, and patient co-morbidities, was obtained from the Electronic Health Record. Participants also completed a Sorting-Working Memory Test, Neuro-QOL Cognitive Function, Anxiety, Depression, and Sleep Disturbance inventories, a modified symptom checklist from the Brain Injury Association of Virginia, and the Disability Rating Scale (DRS) and Satisfaction with Life Scale (SWLS) as measures of physical function and quality of life, respectively. Multiple plasma biomarkers were assayed. The sample was characterized and associations between symptoms, biomarkers, and functional outcomes were examined using linear regression. Group means were calculated for outcomes and biological data, and analysis of variance (ANOVA) was used to compare between-group means.

Results: The sample consisted of 69.23% male participants, with the most common cause of TBI being motor vehicle accident (71.79%). The top 5 symptoms reported by participants included (1) memory problems, (2) difficulty concentrating, (3) easily agitated, (4) trouble focusing with background noise, and (5) having to check and recheck. Of the top 25 symptoms reported by TBI patients, nearly half (12 out of 25) were cognitive symptoms. Changes in concentrations of the biomarkers over time was assessed, and BDNF levels were found to increase (4191.38 ±275.87 pg/ml 3-6 months post-TBI, 5121.33 ±251.70 pg/ml 6-9 months post-TBI, and 5872.92 ±195.54 pg/ml 9-12 months post-TBI, p = .045), while injury severity was not associated with difference in mean concentrations. GCS category and Satisfaction with Life (SWLS) were also significant [F(1, 34) = 5.17, p = .029]. BDNF was inversely associated with cognitive battery outcomes and positively associated with time since injury. S-100β was positively associated with anxiety score, depression score and hospital length of stay; GFAP was also positively associated with anxiety score and hospital length of stay. IL-6 was inversely associated with time since injury and cognitive function.

Conclusions: Several biological markers were associated with functional outcomes during the 3-12-month post-injury period. We found S-100β, GFAP, IL-6 and BDNF to play a larger role in the TBI recovery period than other biomarkers examined. Additionally, focus on cognitive symptoms should be clinically integrated into patient care to improve TBI patient outcomes.

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

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

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

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

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

While the pathophysiology of mild TBI has been described as a “Neurometabolic Cascade of Concussion” it is increasingly evident that this post-injury biology is limited neither to neurons nor metabolism. This talk will extend the previous understanding of post-concussion pathophysiology to include non-neuronal cell types, and beyond purely metabolic changes. At the end of this presentation, participants will 1) understand contributions of astrocytes, microglia, endothelia and oligodendrocytes to post-concussion biology, in addition to neurons, 2) identify both metabolic and non-metabolic post-injury pathophysiology, including changes in synaptic plasticity, white matter myelin, neurovascular unit and glymphatic flow.

TBI is a complex process with a multitude of mechanical and biological components. Post-TBI neurobiology is linked to early clinical signs and symptoms as well as later recovery and persisting sequelae. This talk will illustrate how a more biologically complete understanding of TBI will improve TBI classification and identify actionable targets for treatment and rehabilitation.

The pediatric brain is not just a smaller version of the adult brain. Fundamental developmental concepts underlie distinct biological differences between the immature and mature brain with regards to injury response and recovery. Identifying these neurobiological differences is essential to understand and optimally treat pediatric brain injury.

The cerebellum is not simply a motor-coordination center. This talk will review the anatomical, biological and functional components of the cerebellum. This information will then be projected onto a better understanding of less common and more newly identified functions of this often overlooked but very important brain structure.

There is no single treatment for any complex medical condition, and yet, the quest for a neuroprotective magic bullet for TBI has been the holy grail of neurotrauma research for many decades. Recent advances have increasingly informed a better understanding the complex biological processes underlying TBI across injury types, severities and time post-injury. Identification and validation of objective biological markers can improve future TBI classification, prognosis and intervention, and is now bringing into view a whole new horizon of precision, individualized, mechanism-based therapeutics.

Background: Risk management of concussive blows to the head continues to be a challenge during several occupational and sports activities. Recent evidence suggests that there may be a significant negative relationship between neck strength/endurance and risk levels for concussion. (Collins 2014, Chavarro-Nieto 2021)

Purpose: To evaluate immediate differences in neck strength and endurance with and without customized, optimal mandibular interocclusal appliance positioning.

Design: Cohort Study Design with repeated testing.

Location: University Outpatient Physical Therapy Clinic

Methods: 12 healthy participants (6 females/6 males) ages >18 yrs. were sampled by convenience. Inclusion criteria: normal cervical spine AROM, no recent head or neck trauma or surgery. Exclusion criteria: active cervical pain and any cervical spine postural abnormalities. Participants were fitted with a customized, mouth guard to properly align occlusal "bite" by a dentist while an orthopedic specialist, physical therapist assessed neck extension/flexion/rotation strength using the MicroFit® pressure gauge (Newtons) and grip strength using the Jamar hand dynamometer (kg/ psi). Last of all, timed isometric, cervical muscle contraction for neck flex/extension endurance was measured in seconds. Participants were tested in each activity without and then with the interocclusal appliance in place. Quality of life outcomes including the Neck Disability Index (NDI) and Disability Assessment of Shoulder & Hand (DASH) were used as psychosocial factors or covariates in all analyses.

Statistical Analysis: SPSS (vs.26.0, IBM Inc.) was used for descriptive statistics, paired T-Tests and 2-way repeated measures ANOVA to explore differences at p = 0.05 with a Greenhouse-Geisser correction factor. Multivariate mixed effects models were constructed to assess separate and combined influences of gender and condition on strength and endurance outcomes.

Results: There were significant differences found in strength based on Condition (F (1) 8.834, p =.018) and Position (F (1,8) = 134.226, p < 0.001). Significant differences were also observed in grip strength without vs with the MG (t (8) = -6.378, p < 0.001). There were also significant differences in endurance in both directions: Neck Flex Endurance Test-Supine, (t (8)= -2.334, p= 0.048), Neck Ext Endurance Test-Prone, (t (8)= -4.078, p = 0.002).

Conclusions: Preliminary results indicate a significantly increased neck strength and endurance with a jaw interocclusal appliance for optimized positioning compared to no appliance use.

Clinical Relevance: Suggested gains in cervical spine strength and endurance may assist concussion risk management for contact sports at all levels. Preliminary results also suggest the need for further research about how proper jaw alignment might optimize neck muscle strength over a broad spectrum of subjects regardless of sex, ages or athletic ability.

Traumatic Brain Injury (TBI) constitutes a public health problem around the world that annually claims thousands of lives and is associated with extensive disability and great economic impact; it is defined as the sudden alteration of the brain tissue or its physiological functions as a result of the influence of external forces that exceed the resistance of the tissue. The objectives of this work were to temporally characterize the tissue, behavioral and molecular changes of the hippocampus after moderate TBI in Wistar rats as well as to determine if early management with minocycline can reverse and/or improve the consequences of the injury. It was found that diffuse TBI is associated with neuronal loss in the hippocampus, alterations in the axons and myelin sheaths, as well as reactive gliosis in all subregions, with increased activity of the matrix protease MMP9. Early intervention with minocycline achieved a positive effect on the reduction of neuronal dead, axonal degeneration, and neurofilament compaction with a very slight effect on MMP9 activity. This work is expected to contribute to the knowledge of the phenomena associated with the temporal pathophysiology of diffuse TBI in the hippocampus and further open up the possibilities of pharmacological intervention.

For youth who have sustained moderate to severe ABI, community integration can encompass several components, including home, school, and community participation, satisfying social relationships that include a sense of belonging, involvement in meaningful, purpose driven educational and leisure activities and/or vocational opportunities, as well as developing a level of independence in daily activities. When discharged from acute/post-acute care, there is often a gap between medical care and navigating the school system to assure these students receive appropriate educational supports and services, and again, when exiting school and transitioning into adulthood.

This session will address the characteristics of youth with moderate-severe ABI who may present with barriers inhibiting successful school and community integration, as well as transition to adulthood after exiting the K-12 school system. Strategies and interventions to address a holistic case management approach for a productive community integration experience will be addressed.

Fatigue is one of the most common and disabling symptoms following traumatic brain injury across the spectrum of severity. This lecture will review the definition of fatigue as well as how it is conceptualized including peripheral versus central fatigue. Anatomic areas of the brain implicated in fatigue will be reviewed. Assessment tool for fatigue, the differential diagnosis, medical work up and a range of treatment considerations will discussed.

Sleep-wake disturbances (SWD) are common following TBI, and often extend into the chronic phase of recovery. Such disturbances in sleep can lead to deficits in executive functioning, attention, and memory consolidation, which may ultimately impact the recovery process. We examined if SWDs following TBI were associated with morbidity during the post-acute period. Particular attention was placed on the impact of sleep architecture on learning and memory. Because women are more likely to report SWDs, we examined sex as a biological variable. We also examined subjective quality of life, depression, and disability levels. Data was retrospectively analyzed for fifty-seven TBI patients that underwent an overnight polysomnography. Medical records were reviewed to determine cognitive and functional status during the period of the sleep evaluation. Consideration was given to medications, as a high number of these are likely to have secondary influences on sleep characteristics. Women showed significantly higher levels of disability and reported more depression and lower quality of life. A sex dependent disruption in sleep architecture was observed, with women having lower percent time in REM sleep. An association between percent of time in REM and better episodic memory scores was found. Melatonin utilization had a positive impact on REM duration. Improvements in understanding the impact of sleep-wake disturbances on post-TBI outcome will aid in defining targeted interventions for this population. Findings from this study support the hypothesis that decreases in REM sleep may contribute to chronic disability and underlie the importance of considering sex differences when addressing sleep.

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in the world. TBI induces a chronic disease process causing visual loss which in turn affects day to day life of patients as well as their families. Understanding the underlying molecular mechanisms of TBI-induced vision impairment is a great challenge for neurobiologists, ophthalmologists, and other clinical practitioners. Our animal research study shows that TBI causes damage to the optic nerve and thinning of the retina culminating in compromised vision processing and perception. Axonal degeneration and demyelination in optic nerve and retinal ganglion cells (RGCs) loss in the retina is a crucial feature of vision impairment triggered by TBI. We have found that histone 3 dimethylation at lysine 9 residues (H3K9Me2) on antioxidants gene promoters like SOD can trigger oxidative stress in RGCs and oligodendrocyte precursor cells (OPCs) that was strongly correlated with retinal thinning, impairment of the retrograde transport of axons from visual cortex to neural retina, and demyelination of optic nerve following TBI. Our study suggests that epigenetic regulation of genes associated with oxidative stress could be a potential therapeutic target to restore visual deficits after TBI.

A growing body of evidence indicates that brain injury is a chronic, yet dynamic, condition. A "disease management" approach (BeHEALTHY) has been delineated to provide a proactive model for lifelong management of brain injury. This model, the National Institute on Disability Independent Living and Rehabilitation Research funded BeHEALTHY project, will be described. Essential elements of the BeHEALTHY model include brain health and self-management. Evidence indicates that “brain health” can reduce cognitive decline and promote healthy aging. It is thought that optimizing brain health may be particularly important in the years following brain injury. A Lifestyle Medicine approach promotes brain health through its 6 pillars: plant-based nutrition, physical activity, stress management, avoidance of risky substances, restorative sleep and social connections. Supported self-management refers to education and support provided to individuals and their family members to help them live with chronic health conditions. Self-management support includes education to increase awareness and understanding about a disease and one’s role in decision making, management, and health behaviors. Experience with the application of a lifestyle medicine approach and self-management approach to stroke will be described as well as the potential applications to chronic brain injury due to other causes.

Components of a so called "disease management" approach will be delineated and a proactive model for lifelong management of brain injury will be described. The National Institute on Disability Independent Living and Rehabilitation Research funded BeHEALTHY project will be described including accomplishments to date and forthcoming activities.

This presentation will review research supporting the conclusion that brain injury is a chronic, yet dynamic, condition. Components of a so called "disease management" approach will be delineated and a proactive model for lifelong management of brain injury will be described. The National Institute on Disability Independent Living and Rehabilitation Research funded BeHEALTHY project will be described including accomplishments to date and forthcoming activities.

Brain injury is a chronic, yet dynamic, condition. The chronic and dynamic nature of brain injury demands a different treatment approach. A proactive model for lifelong management of brain injury, The National Institute on Disability Independent Living and Rehabilitation Research funded BeHEALTHY project and results from some of its feasibility projects will be described. The BeHEALTHY investigators completed a comprehensive literature review of guidelines and consensus reports on the assessment and care of chronic brain injury which will be summarized. In an effort to identify best practices for the intake process, NASHIA has compiled the TBI State Partnership program intake assessments. 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. A scoping review of the PRAPARE tool 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.

INTRODUCTION: This case study describes the history of seizure-like events of a 17-year-old Caucasian female diagnosed with spastic quadriplegic cerebral palsy and Lennox-Gastaut syndrome, intractable, with status epilepticus. This individual was enrolled at the International Institute for the Brain (iBRAIN), which establishes and implements an individualized education program (IEP) for each student annually. The student’s 2022 educational plan included mandates of weekly physical (5 h), occupational (5 h), music (2 h individual; 1 h group), and speech-language therapy (5 h). Hearing (0.5 h), vision (3 h), and assistive technology services (1 h) are also included in the student's plan. For academic sessions, the student participated in a 6:1:1 special education classroom.

METHODS: As an academy, iBRAIN does not diagnose seizures. Rather, suspected occurrences were reported as seizure-like events. Information captured from a seizure-like event include, but not limited to, time of day, sensory stimulation and service rendered at time of the event, prior state of arousal, and vital signs during the postictal phase. Pulse rate, respiration rate, and saturated oxygen levels were taken, using an over-the-counter pulse oximeter with respiratory rate device (Item # 793251, Walgreens Boots Alliance, Inc., Deerfield, IL). Herein, we conduct statistical analyses of the reported seizure-like events, giving consideration to time of day, sensory stimulation, arousal level, and vital signs.

RESULTS: Within a 16-week period, 38 seizure-like events were reported during this student's school attendance. The observed frequency distribution of seizure-like events throughout the day was different (P < 0.05) from its expected distribution (i.e., equivalent number of occurrences throughout the day). The occurrence of seizure-like events was influenced (P < 0.05) by the type of sensory stimulation. Altogether, the highest seizure-like event occurrence was (in descending order) during a combination of sensory stimuli, feeding, visual, auditory, and movement. Notably, no seizure-like events were reported when the service sessions were primarily stretching exercises. In sessions where seizure-like events were reported, the mean pulse rate was 22 beats per minute higher (P < 0.05) than when no event was reported. Likewise, the mean number of respirations per minute was higher (P < 0.05) when seizure-like events were reported. Saturated oxygen levels did not differ statistically, when comparing sessions with the presence or absence of seizure-like events.

CONCLUSION: Understanding patterns of seizure-like events in a school setting could be used to dose or titrate educational and related service sessions. In this case, accommodation for arousal level and increased integration of muscular stretching may be indicated.

This presentation will highlight the state of the art research related to the neuroscience of music and its application across diagnoses in neurorehabilitation. The presentation will also highlight novel technology that has advanced in clinical application of this research. Oral presentation, video examples, and interactive demonstrations will be incorporated throughout.

Concussions involve symptoms that arise following mild traumatic brain injury (mTBI). There is limited understanding about the evolution of concussion symptoms, particularly among children. This limits clinicians’ ability to predict concussion duration, or even define persisting post-concussive symptoms (PPCS). The objective of this study was to characterize the trajectory of concussion symptoms among youths and define the prevalence of PPCS.

This cohort study included 1132 youths, 12-21 years. There were 399 youths with mTBI (enrolled 2.9 ± 2 days after mTBI) and 733 without mTBI. Both groups were recruited at emergency departments and outpatient clinics. The Post-Concussion Symptom Inventory (PCSI) was used to assess 22 concussion symptoms. In total, 2074 PCSI were completed: 1076 uninjured ratings (865 from youths without mTBI, and 211 retrospective estimates from youths with mTBI); 998 longitudinal ratings from youths with mTBI: 390 at enrollment, 351 at 1-2 weeks, and 257 at 1 month. Uninjured ratings were used to determine mean symptom burden in the absence of mTBI. Longitudinal ratings were used to characterize symptoms after mTBI. Incidence of PPCS 1 month after mTBI was assessed with 3 approaches: 1) compared to individual uninjured symptoms; 2) compared to the mean symptom severity of uninjured youths; 3) using one question, “What percentage of normal do you feel?” (>95% at 1 month = recovered).

Participants were 49% male, 77% white, and 9% Hispanic. The majority were in in high school (44%) or middle school (32%), and 69% were athletes. History of headaches (29%), attention problems (30%), and depression (25%) were common. Many (22%) had a prior mTBI. Uninjured youths endorsed 6.7 of 22 symptoms, with a mean symptom severity of 16 out of 132. Following mTBI (n=399), mean symptom severity was 36 at enrollment, 19 at 1 week, and 9 at 1 month. Headache was the most common symptom at enrollment (88%), 1 week (66%), and 1 month (38%). Difficulty concentrating (33%) was also common at 1 month. One month after mTBI, 35% met PPCS criteria compared to personal uninjured ratings, 25% met PPCS criteria compared to the mean symptom severity of uninjured youths, and 30% met PPCS criteria based on estimated “percent normal.” There was significant agreement between measures (ĸ = 0.62, p < 0.001).

Many youths endorse concussion-like symptoms, even without mTBI. Headache is the predominant symptom in the first month after mTBI. Rates of PPCS in youths are 25-35%, and may be captured with a single self-report question, “What percentage of normal do you feel?”

The special operator forces (SOF) community is accustomed to efficiency and mission driven work. The inherent occupational demands, and the cumulative effects of intense trauma (both physical and psychological), blasts and other exposures, all contribute to impairments and injuries specific to the work environment. Thus, expert interdisciplinary care for SOF incorporates both expeditious assessments with five-day Comprehensive Brain Health and Trauma program (ComBHaT), and a tailored treatment program, or two-week intensive clinical program (ICP). Physical, psychological, neurological, medical, and musculoskeletal impairments interact and impact one another, and a comprehensive evaluation is not fully complete without best practice communication among clinicians who are directly assessing SOF. Interdisciplinary SOF care includes psychological diagnostics, cognitive assessment with neuropsychology, vestibular-oculomotor evaluation with physical therapy, nutrition, sleep assessment, and concomitant various specialty medical opinions including neuroendocrinology and neurosurgery. Comprehensive laboratory work in addition to neuroimaging are essential tests to complement complete clinical evaluations. Risk of morbidity, including oncologic disease, resulting from specific toxic and environmental exposures is taken into consideration in this younger, predominantly male population. We can also look to comparable work in professional football players regarding brain health and multisystem disease that affect both longevity and quality of life in the SOF population. One’s healthspan is defined as the years of life that do not include chronic disease, and research in football has shown that early aged cardiovascular impairments, musculoskeletal, and cognitive challenges are associated with reduced healthspan. The Home Base Program is a unique example of a non-profit care system well positioned to take care of the SOF population, in the context of the imperative need for private-government partnerships to meet the growing demand to address these invisible wounds of war, and mitigate morbidity while promoting strong quality of life for the SOF community.

Acute traumatic brain injury (TBI) exerts damage to the brain through an external force that activates a cerebral inflammatory response. In some cases, maladaptive inflammation may result in chronic inflammatory conditions and/or changes to the gut microbiome. Inflammation and the gut microbiome have a complex bidirectional relationship that plays a part in neurogenerative processes, behavior, and cognition. Currently few treatment options exist for TBI patients, therefore a better understanding of biological responses that are connected to physical and mental health outcomes is needed in human studies. In this study, longitudinal sampling was conducted from emergency department patients with post-acute mild TBI (mTBI). Samples included the fecal microbiome within 48 hours of admission (baseline) and at monthly intervals for up to 12 months in 23 participants for 167 total fecal samples (mean >7 samples per participant). Plasma was collected at baseline for all participants and at 12 months for a subset of 11 participants and analyzed for changes in inflammatory markers (i.e., C-reactive protein, interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor). Data regarding psychological histories/symptoms were obtained at baseline and each month of participation. Preliminary analysis was conducted to explore the microbiome and inflammatory changes post-acute mTBI. In a linear mixed model to account for related samples from the same participants, the overall microbial community was significantly divergent across the sampling time when compared to baseline. A rapid reduction in abundance, with no long-term recovery, of the potentially anti-inflammatory genus Akkermansia partially explained the trend. Akkermansia muciniphila promotes intestinal barrier function, in part by enhancing mucus production. A similar trend was not observed in other genera commonly associated with anti-inflammatory effects (e.g. Bacteroides, Faecalibacterium, Lactobacillus). Plasma concentrations of IL-6 were significantly reduced from baseline to 12 months, consistent with previous studies documenting elevated plasma concentrations of IL-6 immediately after a TBI. Findings support previous work highlighting relationships between TBI, inflammatory response, and the gut microbiome. Analysis of the factors associated with changes in the gut microbiome and/or biomarkers of inflammation is ongoing, including analysis of associations of physiologic responses with mental health outcomes subsequent to post-acute mTBI.

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

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

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

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

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

Traumatic brain injury (TBI) is a condition that can cause oxidative stress, inflammation, and cell death in the brain. Antioxidant therapies have been studied as a potential treatment for TBI, including hydrogen treatment. Si-based agent continues generating hydrogen for more than 24 hours by the reaction with water and generates approximately 400 mL of hydrogen. However, there is no specific information available on the effectiveness of Si-based agents for TBI. This study aimed to investigate the beneficial effects of the Si-based agent for TBI in a mice model. We used the controlled cortical impact model (CCI) mice. The mice were fed a control diet or a diet containing the Si-based agent for one week before CCI. One week after CCI, the Y-maze and open-field tests were performed as behavioral tests. As a result, mice treated with Si-based agents (n=19) showed a notable increase in the spontaneous alternation values compared to the control group (n=19) (control group vs treatment group = 61.7% (51.9-69.2%) vs 74.2% (60.3-85.7%): p=0.03). However, there were no significant differences between the control group and treatment group in the open-field test (time in the inside zone; control group vs treatment group = 27.2 seconds (22.6-34.5 seconds) vs 30.1 seconds (16.8-34.2 seconds): p=0.99, total distance; control group vs treatment group = 29.1 meters (22.5-34.3 meters) vs 28.8 meters (23.1-35.8 meters)). These findings indicate that the Si-based agent is found to prevent impairment of spatial learning and memory after CCI, which should be considered as a novel hydrogen administration method for TBI.

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

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

The definition of mild traumatic brain injury (TBI) published by the American Congress of Rehabilitation Medicine (ACRM) in 1993 has guided clinical practice and research over the past 25 years. In 2019, the Mild TBI Task Force of the ACRM Brain Injury Special Interest Group undertook updating the definition and diagnostic criteria for mild TBI. This work included rapid evidence reviews, an expert survey (to rate the diagnostic importance of various clinical signs, symptoms, test findings, and contextual factors), public and stakeholder engagement, and a Delphi consensus process with an international, interdisciplinary panel of clinician scientists. The new diagnostic criteria were published in the summer of 2023. This presentation will provide an overview of these activities and then present the new consensus diagnostic criteria for mild TBI. Case examples will be presented to illustrate how the diagnostic criteria can be applied.

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

This study examines hypoxic ischemic brain injuries in the context of cerebral palsy (CP) in India. Children with CP commonly experience issues like epilepsy, hearing loss, and feeding difficulties. These feeding problems result from communication barriers, oral-motor dysfunction, and aspiration. Despite various assessment tools for feeding issues, there's a lack of options in Indian languages. This study focuses on the complexities of hypoxic ischemic brain injuries, particularly within the context of CP. The objectives of the study are to evaluate the impact of hypoxic and ischemic brain injuries on individuals' neurological and cognitive functions and provide observational insights to enhance the scientific understanding of these injuries.

The research took place in Pune, Maharashtra, employing a cross-sectional design and convenient sampling. Marathi-translated version of the Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was utilized, comprising 35 items. These items allowed parents to assess both their child's eating behaviors and their own feelings or strategies concerning feeding issues. The translated BPFAS was administered to parents of children diagnosed with CP. Using the Marathi-translated BPFAS, the questionnaire was structured into five categories: 'Picky Eaters,' 'General Toddler Refusal,' 'Toddler Refusal—Textured Foods,' 'General Older Children Refusal,' and 'Stallers.'

A sample was gathered from the School of Audiology and Speech Language Pathology at Bharati Vidyapeeth (deemed to be a university). Out of the initial group of 50 participants, aged between 9 months and 7 years and diagnosed with cerebral palsy (CP), two participants declined to provide consent for the study, and 21 participants were excluded due to not meeting the inclusion criteria. The inclusion criteria required parents to be native Marathi speakers and their children to be aged 9 months to 7 years with CP attributed to hypoxic ischemic encephalopathy; the rest were excluded.
A descriptive analysis calculated standard deviations and means, revealing no significant gender impact on BPFAS scores. Notably, the study identified distinct feeding challenges among children with CP who displayed milder picky eating tendencies, while younger children in the 'General Toddler Refusal' category exhibited common issues like whining and food refusal. The 'Toddler Refusal—Textured Foods' category emphasized difficulties with specific food textures, underscoring the need for tailored interventions. Additionally, the 'General Older Children Refusal' and 'Stallers' categories highlighted CP-related behaviors in food choice negotiation and eating habits. This study offers valuable insights into mealtime behavior patterns in children with CP, underscoring the significance of tailored feeding interventions.

In conclusion, this study sheds light on the multifaceted challenges faced by children with CP in India. The prevalence of CP, its associated comorbidities, and the impact on feeding and communication are important considerations. The findings highlight the pressing need for high-quality prevalence studies in India to better understand the CP landscape and its associated issues.

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.

Navigating care following the initial hospital discharge can be a complex and vulnerable time for individuals with Traumatic Brain Injury (TB). After acute hospitalization, individuals with TBI may be discharged to different postacute settings, not limited to: inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), long-term acute care hospitals (LTCH), and home health (HH). When the right transitions are not made at the right times, individuals with TBI face poor outcomes such as hospital readmissions. Also, there exists disparity in these care transitions by gender, race/ethnicity, and living situation (rural versus urban settings). Our study objectives were, to examine care transitions patterns and differences for individuals with TBI in a 90-day post-hospitalization period, and to examine 30- and 90-day hospital readmission risk. This was a retrospective cohort study. We conducted secondary analysis of data from Virginia All-Payer Claims Database (APCD) for the years 2027-2021. Virginia APCD comprised of commercial, Medicare, Medicaid, etc. claims from about 5 million Virginia residents associated with health services (acute, postacute, and community-based) utilization. We selected records of individuals with TBI admitted to acute hospitals and followed their care transitions through postacute and community-based health services in 30- and 90-day follow-up period. We also calculated risk adjusted 30- and 90-day hospital readmission and examined if the hospital readmission risk is different by gender, race/ethnicity, locations, and type of postacute services they received, controlling for all the other covariates. Our analytical cohort comprised of 18,215 individuals with TBI with index acute hospitalization in the years of 2017-2021. The mean age of our cohort was 70.8 (18.7) years, 51% male, 33% non-white, and 5% living in rural locations. Only 61% (11,106) of our study cohort received any postacute care, with 30% going to SNFs, 18% to HHs, and 12% to IRFs. The unadjusted 30-day readmission rate was 3.6%, and 5% for 90-day hospital readmission. In the fully adjusted models, controlling for other covairtaes, we found higher likelihood of 30-day hospital readmission for those going to SNFs (OR=1.9, 95%CI=1.5-2.4), and IRFs (OR=2.9, 95%CI=2.3-3.8) relative to those without any postacute follow-up. Also, we found lower likelihood of 30-day hospital readmission for Blacks compared to non-Hispanic Whites (OR=0.68, 95%CI=0.50-0.93). For 90-day hospital readmission, we found higher likelihood with SNFs and IRFs discharges and lower likelihood for Blacks as compared to non-Hispanic Whites. Our study findings highlight need for equitable access to postacute care is an important consideration for individuals with TBI to maintain care continuity, and achieve desirable health outcomes, and more importantly avoidance of undesirable outcomes, such as hospital readmissions.

Introduction:
The assessment of consciousness in patients who have sustained a severe brain injury in the intensive care unit (ICU) poses a significant challenge. Covert consciousness refers to a state where patients exhibit no overt signs of behavioral responsiveness, yet their brain activity – as indexed through functional neuroimaging - demonstrates preserved awareness and cognitive function. In the ICU setting, accurately identifying such cases is crucial for appropriate patient care and medical decision-making. Functional near-infrared spectroscopy (fNIRS) is a promising modality for measuring and mapping brain function, as it is portable and can be safely used at the bedside This study explores the feasibility of using fNIRS to detect covert consciousness in patients with acute brain injury in the ICU.

Methods:
16 behaviorally unresponsive ICU patients with varying brain injury etiology were enrolled. Patients were asked to imagine playing a game of tennis while undergoing fNIRS monitoring. The fNIRS technique enables the measurement of cerebral hemodynamic changes associated with cognitive processes, providing a window into the neural activity underlying motor imagery. 24 age and sex-matched healthy controls were also enrolled. The fNIRS setup consisted of a 129-channel NIRScoutXP system. A channel was considered activated if there was a significant increase in oxyhemoglobin and a concurrent decrease in deoxyhemoglobin (p<0.05).

Results:
Of the 16 patients tested, two demonstrated the ability to follow commands during the motor imagery task despite the absence of observable signs of behavioral consciousness. Analysis of the fNIRS data revealed distinct patterns of neural activation during the motor imagery task in both patients and healthy controls. These findings were supported by positive responses to a language comprehension task.

Discussion:
This study highlights the capability and feasibility of fNIRS to detect convert consciousness in patients who appear behaviourally non-responsive in the ICU. The results underscore the need for more nuanced and sensitive approaches to consciousness assessment in critical care settings. Further research and validation of fNIRS as a tool for detecting covert consciousness could revolutionize our understanding of patient awareness in the ICU, impacting treatment decisions and enhancing patient care strategies.

Post-acute brain injury rehabilitation has the potential to drive meaningful recovery and support long-term sustainable outcomes when designed correctly. Emphasizing the principles of learning, a program design will consider the clinical model in addition to team structure, cultural norms, and facility design. Individualization of programming matched to the values and goals of the participants facilitates engagement and ties the “tasks” of rehabilitation to the individual’s functional needs. This session will reveal some of the key elements in creating an effective residential rehabilitation model that focuses on recovery of the whole person and re-establishment of a meaningful life path.

BACKGROUND: Post-9/11 U.S. Veterans are clinically complex with multiple co-occurring health conditions contributing to morbidity/mortality and decreased quality of life. Traumatic Brain Injury (TBI) diagnosis can worsen these outcomes. STEP-Home is a cognitive-behavioral transdiagnostic intervention for TBI and common comorbidities.

OBJECTIVES: Determine if STEP-Home improves anger and impulse control, frontal system function, civilian readjustment, neurobehavioral symptoms, and work/life functioning in post-9/11 Veterans. TBI may influence Veterans’ ability to learn core skills and, thus, impact response to treatment. Treatment outcomes for Veterans with and without TBI will be explored.

METHODS: A total of 56 (39M/17F; mean age = 40) post-9/11 Veterans with high rates of psychiatric comorbidity, with and without TBI received 12 weeks of the STEP-Home transdiagnostic group intervention. STEP-Home sessions teach cognitive behavioral skills relevant across diagnostic category, including Problem Solving (PS) and Emotional Regulation (ER). These skills are integrated and applied across Veteran-specific content areas to assist in community reintegration and functioning. Assessments at baseline, posttreatment (12 weeks), and follow-up (24 weeks) included: State-Trait Anger Expression Inventory 2 (STAXI-2); Military to Civilian Questionnaire (M2CQ); Post-Deployment Readjustment Inventory (PDRI); Frontal Systems Behavioral Scale (FrSBe); Neurobehavioral Symptom Inventory (NSI); World Health Disability Scale (WHODAS); PTSD Checklist (PCL-5); Depression Anxiety and Stress Scale (DASS-21).

RESULTS: STEP-Home significantly improved anger expression (STAXI-2 p = .0320), inhibitory control (FrSBe p =.0001), and reintegration status (MC2Q p=.0001; PDRI p =.0097) posttreatment. Similar improvements were seen in neurobehavioral symptoms, work/life functioning, PTSD, depression, and stress (p’s < .01). Treatment gains were maintained at follow-up (p < .001). Treatment response did not differ by TBI status.

CONCLUSIONS: STEP-Home teaches Veterans cognitive-behavioral skills to improve anger, impulse control, executive functioning, reintegration, and work/life functioning. STEP-Home is equally as effective for participants with and without TBI. There was no effect of TBI status on treatment maintenance over time. This is critical given TBI prevalence among post-9/11 Veterans and the need for additional palatable treatment options.

The objective of this secondary analysis was to examine the relationship between extreme pain phenotypes (based on pain interference and perceived improvement) and psychosocial outcomes among persons with chronic pain after moderate-to-severe traumatic brain injury (TBI). In total, 1762 TBI Model Systems (TBIMS) participants 1 to 30 years postinjury reporting chronic pain were recruited as part of a multisite, cross-sectional, observational cohort TBIMS addendum study on Chronic Pain. Extremely low and high pain phenotypes were identified by the Brief Pain Inventory (BPI) interference scale, and the Patient’s Global Impression of Change (PGIC). Clinical outcomes of interest included life satisfaction, posttraumatic stress, depression and anxiety symptoms, sleep and participation. Generally, extreme phenotypes based on interference had greater association with psychosocial outcomes compared to improvement-based phenotypes. Those identified as extremely high pain interference phenotype had poorer psychosocial outcomes compared to the extremely low phenotype group. After controlling for covariates, large effect sizes (ES) related to pain interference were observed for posttraumatic stress symptomatology (ES = -1.14), sleep quality (ES = -1.10), depression (ES = -1.08), anxiety (ES = -0.82), and life satisfaction (ES = 0.76); effect sizes for participation outcomes, although significant, were relatively small (ES = 0.21-0.36). Effect sizes related to perceived improvement were small for life satisfaction (ES = 0.20) and participation (ES = 0.16-0.21) outcomes. Pain intensity was identified as a meaningful confounding factor of the relationships between extreme phenotypes and posttraumatic stress, depression, anxiety, and sleep quality. Results suggest that the relationships among a variety of characteristics of the person, their experience with pain, and treatment of pain are complex. However, examination of subgroups defined by extreme phenotypes of interference (and to an extent, perceived improvement) were able to identify pronounced differences in the psychosocial experience of individuals living with chronic pain and TBI. Further research is needed to better understand these complex relationships and how differences in pain interference and perceived improvement from treatment can assist in assessment and treatment of chronic pain after TBI.

BACKGROUND: Insomnia disorder and obstructive sleep apnea (OSA) are common co-morbidities among Veterans with mild traumatic brain injury (mTBI). Clinical practice guidelines include recommendations for evidence-based interventions that effectively treat insomnia (e.g., cognitive behavioral therapy for insomnia) and OSA (e.g., positive airway pressure), but clinical benefit depends on Veterans’ consistent adherence to treatment. While adherence to interventions for insomnia disorder and OSA are challenging for many patients, Veterans with mTBI may experience unique barriers worthy of consideration. However, such barriers to adherence are poorly understood in this population. The purpose of this study was to understand factors influencing adherence to recommended treatment for insomnia and OSA among Veterans with mTBI.

METHOD: Semi-structured interviews (n=49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach.

RESULTS: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., mTBI sequalae), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support).

CONCLUSIONS: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population, ensuring they sustain treatment engagement and reap the desired clinical benefits.

This session was built from submitted abstracts and pairs laboratory with clinical studies to identify and intervene in the treatment of traumatic brain injury. The talks will focus on pain, inflammation, and nutrition as chronic co-morbidities, with mention of mechanisms that can be targeted for therapeutic interventions. The six 12-minute talks will be followed by an integrated and moderated discussion by the panel co-chairs.

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

This is the case of a 48-year-old female with a past medical history of hypertension who presented to the emergency room with “the worst headache” of her life. She was found to have diffuse subarachnoid hemorrhage and left frontal intraparenchymal hemorrhage, requiring ventriculoperitoneal shunt placement. After the procedure, the patient complained of new-onset bilateral lower extremity paresthesias and weakness. Lab results ruled out cobalamin and folate deficiencies. Electrodiagnostic studies showed bilateral lumbosacral root dysfunction primarily affecting L5-S2. Lumbar MRI showed clumping and diffuse enhancement of cauda equina nerve roots. These findings raised concern for possible arachnoiditis. Arachnoiditis is defined as a persistent inflammation of arachnoid mater that involves membrane thickening, dural adhesions, and clumping of nerve roots. It has no well-defined epidemiology and is considered quite rare and difficult to diagnose. Potential causes for arachnoiditis range from physical or chemical irritants such as injections, surgery, infectious causes such as HIV or TB, or mechanical irritants such as subarachnoid hemorrhage. It has variable timing from the onset of injury until clinical manifestations appear and presents with varying imaging results. Clinically, patients present with an insidious onset of chronic and debilitating pain, most commonly back pain, progressing to radicular pain and sensory defects. Arachnoiditis is managed with supportive care such as physical therapy, pain medication, muscle relaxants, and neurostimulation. It often goes unrecognized and untreated because it is exceedingly rare and difficult to diagnose. Understanding the causes of arachnoiditis and detecting the signs on imaging and physical examination is important to cultivate treatment regimens for future patients. With supportive management through medication and physical therapy, our patient has shown improvement in symptoms and functionality.

The landscape of prolonged symptomatology and functional impairments following traumatic brain injury (TBI) can become perplexing and enigmatic to unravel etiologically. This constellation of TBI-induced symptoms can present curious, latent emerging symptoms which are difficult to distinguish across clinical settings. Since the specific biomechanics and aerodynamics involved in each injury scenario can vary widely, the combination of variability across individual coping styles, as coupled with personalized immune system responses, can interactively determine lingering and evolutionary injury-induced symptom sequelae. A sizeable amount of these persistent, post-morbid TBI symptom profiles may functionally overlap, and can feature multi-organ-system involvement. As an additional complication, impaired symptom awareness can amplify TBI-induced trauma and PTSD symptomatology for the injured individual, since an association to actual injury dynamics often goes underrecognized, and/or misdiagnosed, subsequently postponing essential treatment(s). When an injured individual discloses or displays curious, continuous and/or newly emerged TBI-related symptoms which are not taken seriously by others, these courageous communications may become misunderstood, dismissed, disbelieved, and underappreciated. Misinterpretation of symptom self-disclosures as being insincere, confabulated, or malingering can be difficult to cope with, especially when originating from family, friends and across other meaningful relationships. These discrediting impressions add baffling layers of burden to an individual suffering with a TBI, complicating the already challenging task of healing and recapturing pre-injury functioning. When the response of others involves questioning the authenticity of prolonged symptoms, this feedback translates atmospheric doubt, conveying non-supportive recovery expectations. This stress provocative dynamic can dilute relationship integrity, induce trauma triggers, reactivate, and amplify residual PTSD, and compound unresolved, post-morbid symptoms for the injured individual. A self-protective avoidance response of social disengagement is common, as the individual withdraws or self-isolates to minimize negative exposure impact. Essential treatment targets should encompass a thorough exploration of pre-morbid vs. post-morbid profiles, based on patient self-report, collateral input, and findings from standardized testing aimed at assessing and quantifying post-morbid functional impairment(s) and pre- vs. post-morbid discrepancies. Referral to well-informed, multidisciplinary providers who rely on evidence-based, specialized ancillary services can assist in discerning symptom persistence and its link to TBI-related events, while expediting multimodal interventions as may be warranted. A two-pronged psychotherapeutic approach should prioritize providing guidance and support in identifying and recognizing unrelenting post-morbid symptom comorbidities featuring neuropathophysiological, multi-system involvement. Secondly, evidence-informed psychoeducation should include didactic, portable coping skills which focus on tracking routine functioning across atmospheres, monitoring sleep architecture, nutrition, integrating modest exercise, budgeting energy output, mood regulation, promoting a self-healing mentality, and bolstering confidence in healing, health resilience and recovery. Restoring a sense of dignity for the TBI-injured individual by validating symptom legitimacy and launching endeavors to clinically investigate symptom etiology via referral(s) and clinical collaboration with multidisciplinary providers are essential approaches in addressing prolonged TBI-induced symptomatology.

Pediatric traumatic brain injury may consider expanding to include perinatal events and exposures involved in complicated childbirth, since research reveals adverse influences for child neurodevelopmental trajectory. Epidemiological studies link specific intrapartum complexities presenting during labor and delivery with rising child neuropsychiatric outcomes, justifying the novel concept of perinatal neurotrauma. These overlapping, interacting factors combined with elevated maternal gestational BMI, confer a disruptive cascade of neural events which may risk lifelong impairments for children. Rising neuropsychiatric conditions including ADHD and Autism have unconfirmed etiologies, yet complicated childbirth associations. Concomitant cognitive dysexecutive symptoms, emotional dysregulation, social and academic issues often persist into adulthood. While research has considered genetic etiology, it is unlikely genetics alone trigger these outcomes. Plausibly, events introduced during most sensitive developmental periods may affect the malleable fetal brain with risky downstream effects, altering child neurodevelopment. Birth complications typically involve well-respected measures aimed at expediting childbirth. One first-line, synthetic uterine simulant effectively assists > 50% of all U.S. childbirths, despite its poorly understood fetal impact. Exponential increases in exogenous uterine stimulation and dosage inconsistencies raise concerns of consequential maternal-fetal transmission. Labor duration and pharmacological dosages are important algorithms to disentangle since these are all modifiable factors. Established repercussions of this early environmental exposure include fetal distress, low Apgar scores, uterine hyperactivity, FHR abnormalities, NICU admissions and ischemia/asphyxia/hypoxia. Putative neuropathophysiological models include fetal intolerance to prolonged dosages, labor impact; epigenetic triggering, oxytocin receptor hyperstimulation and/or receptor oversaturation. Other considerations include neuroinflammation; hypertonic uterine contraction pressure imposing neuropathogenic alterations and diffuse axonal injury. Plausibly, disharmonious compounds, GABA downregulation; blood-brain barrier breach and/or placental permeability may interactively compromise fetal neuroprotective integrity. Additionally, the underexplored neuropathophysiological interpretation of pharmacokinetics involving synthetic properties may play a key role in fetal brain impact. Interestingly, maternal BMI/adiposity, a modifiable gestational health factor, increases odds for medically assisted childbirth owing to diminished uterine contractility in obese mothers. The shared effects of maternal BMI with chemically expedited labor, and its two-fold impact on offspring brain development is under-investigated, begging further exploration since its potential future contribution to the study of pediatric traumatic brain injury is imperative. While a signature, underlying, neuropathophysiological mechanism(s) linking childbirth complications and maternal gestational BMI to pediatric brain injury lacks confirmation, mixed evidence associates these factors directly with child neuropsychiatric phenotypes. Logically, the vulnerable fetal brain’s reaction to early, overlapping events and exposures is important to better understand. It is crucial to appreciate that a constellation of perinatal factors may risk future functional and behavioral impairments for children. Early vulnerabilities, potentially linked to in-utero exposures and obstetric dynamics, may destabilize and/or disrupt fetal brain development, warranting aggressive research and inclusion in the burgeoning field of pediatric brain injury as a critical child public health issue.

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

The most recent International Consensus Conference on Concussion in Sport was held in Amsterdam in 2022. New evidence-based guidelines have emerged since the last conference held in Berlin in 2016 that will impact concussion care worldwide. At the end of this presentation, learners will be able to describe: (1) Updates to the diagnosis, assessment and management of Sport-related concussion (SRC); (2) Strategies for helping return concussed athletes to school; and (3) Strategies for helping return concussed athletes to sport.

Persisting symptoms after concussion/mTBI are not a single “post-concussion syndrome”. There is an emerging differential diagnostic and evidence-based treatment approach that all clinicians should be aware of and employing in their practices. At the conclusion of this activity, participants will be able to: (1) Describe the differential diagnosis of Persisting Post-concussive Symptoms (PPCS); and (2) Describe the treatment for the various symptom generators of PPCS.

Objective: Sport-related concussion (SRC), a subtype of mild traumatic brain injury (mTBI), is common in adolescents. A common clinical outcome of SRC is the development of new anxiety and depressive mood symptoms, which can impair SRC recovery. This study assesses the effect of early, targeted aerobic exercise treatment versus a placebo-like stretching program on recovery in adolescent athletes who report high and low initial mood symptom burden after SRC.

Methods: Exploratory secondary analysis using data from two randomized trials collected in four outpatient clinic settings. Male and female adolescents (13-18 years) diagnosed with SRC within ten days of injury were divided into low (< 6/24 points) or high (≥ 6/24 points) burden based on self-reported symptoms of irritability, sadness, nervousness and feeling more emotional on a 0-6 Likert scale. The main outcome measure was recovering during the intervention period and incidence of Persisting Post-Concussive Symptoms (PPCS).

Results: Out of 198 adolescents with SRC, 156 (79%) reported a low burden of mood symptoms (mean = 1.2 ± 1.65) and 42 (21%) reported a high burden (mean = 9.74 ± 3.70) before randomization. The effect of intervention (exercise versus stretching) was not significant in the low mood symptom burden group (hazard ratio = 0.767, p = 0.128) and was significant in the high burden group (hazard ratio = 0.290, p = 0.005). This corresponds to a 71% reduction in risk for PPCS in the high burden group. High burden of mood symptoms had a positive correlation with high physical, cognitive and sleep symptoms, and a higher number of abnormalities on physical exam, but did not correlate with participant sex or level of exercise tolerance.

Conclusions: Early prescribed aerobic exercise treatment facilitates recovery and significantly reduces the incidence of PPCS in adolescents reporting a high burden of new onset mood symptoms after SRC and should be considered as part of a comprehensive treatment plan for these patients.

At the end of this presentation, learners will be able to describe recent updates to the diagnosis, assessment, and management of Sport-related concussion (SRC) and of Persisting Post-concussive symptoms (PPCS) from the 6th International Consensus Conference on Concussion in Sport held in Amsterdam in 2022. The lecture will also inform the learner on strategies for helping return concussed athletes to school and to sport and will present the most recent thinking on risk of long-term problems after concussion such as CTE.

OBJECTIVE: Accessibility to accurate and comprehensive information is crucial for patients and caregivers after a traumatic brain injury (TBI). While fact sheets offer standardized information, the rise of chat-bot artificial intelligence (AI) presents an alternative source of information. This study evaluates and compares the accuracy and comprehensiveness of responses from ChatGPT-3.5 and ChatGPT-4.0, utilizing the most-viewed TBI fact sheets from the Model Systems Knowledge Translation Center (MSKTC) as the gold standard.

METHODS: Five TBI fact sheets were chosen from the MSKTC based on total views from 12/1/22-5/31/2023. Subheadings from the fact sheets were formatted into questions to simulate real-world queries. These questions were posed to both ChatGPT-3.5 and ChatGPT-4.0. Its output was compared to corresponding MSKTC fact sheet content and was scored by 3 blinded, independent graders using a 1-5 Likert scale based on accuracy, comprehensiveness and additional factual and useful information. The mode score among graders was used as the consensus score.

RESULTS: Analysis of 38 prompts demonstrated a significant difference in accuracy and comprehensiveness scores between ChatGPT-3.5 and ChatGPT-4.0 (p = 0.04). The mean ChatGPT-4 score was 3.63 (SD = 0.94), indicating its responses were generally accurate but occasionally lacked comprehensiveness. In comparison, ChatGPT-3.5 had a mean score of 3.21 (SD = 0.84), indicating its responses were mostly accurate but often missing key details present in MSKTC fact sheets. The standardized mean difference (SMD) was -0.47 (95% CI: -0.92, -0.01). Further analysis of individual spreadsheets showed that ChatGPT-4.0 outperformed ChatGPT-3.5 in regards to discussing details about the vegetative state, the relationship between memory and TBI and the relationship between headaches and TBI.

CONCLUSION: This study demonstrates the advancements in AI from ChatGPT-3.5 to ChatGPT-4.0, with the latter showing a statistically significant improvement in accuracy and comprehensiveness when providing information on traumatic brain injuries. While both versions of ChatGPT can serve as valuable tools for disseminating TBI information, ChatGPT-4.0 appears to be a more reliable source, particularly in discussing complex topics like vegetative state and memory-related issues post-TBI. However, caution is advised as occasional gaps in comprehensiveness were observed in both versions. Continued advancements in AI and regular updates based on reliable sources such as MSKTC are essential for optimal patient and caregiver support.

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

Managing concussions and TBI remains a complex challenge in sports medicine and healthcare. A one-size-fits-all approach isn’t going to work. While current standard of care primarily involves rest and symptomatic management, emerging research suggests that active recovery and specific nutritional strategies may expedite concussion recovery. Therapies targeting the inflammasome are essential to maintain or regain brain health after injury. Presented here is a comprehensive overview of the potential efficacy of targeted nutritional interventions in ameliorating the effects of concussions and diminishing the risk of recurring injuries.

There exists a complex interplay between omega-3s and omega-6s and the endocannabinoid system. The endocannabinoid system has well-established roles in neuroinflammation, synaptic plasticity and neurogenesis. The endocannabinoid system comprises cannabinoid receptors, their endogenous ligands, the endocannabinoids, and their biosynthetic and degradation enzymes. Arachidonic acid (ARA) and docosahexaenoic acid (DHA) are essential for optimal brain development and function with and through the cannabinoid system. Omega long-chain polyunsaturated fatty acids (LCPUFA), including ARA, DHA, and EPA (eicosapentaenoic acid), are essential components of membrane phospholipids and precursors to a number of bioactive lipid mediators. Anandamide (AEA) and 2-arachidonoylglycerol (2-AG) are the most widely studied endocannabinoids and are both derived from phospholipid-bound ARA. Yet, DHA and EPA supplementation reduce AEA and 2-AG levels, with reciprocal increases in levels of the analogous endocannabinoid-like DHA and EPA-derived molecules, docosahexaenoyl ethanolamide (DHEA) and eicosapentaenoyl ethanolamide (EPEA). Dietary enrichment with DHA and EPA have shown beneficial effects on learning and memory, neuroinflammatory processes, synaptic plasticity, and neurogenesis.

This review contributes to the evolving landscape of concussion management by highlighting the pivotal role of targeted nutritional therapy as a therapeutic approach. These interventions can modulate neuroinflammation, enhance neuroprotection, and facilitate neurorepair following a concussion. Furthermore, practical considerations for implementing targeted nutritional interventions across diverse populations, from athletes to military personnel and individuals at risk of recurrent head injuries, are to be addressed. This underscores the importance of acknowledging nutrition as a complementary strategy in the multifaceted domain of concussion management and prevention. As we persist in our endeavors to augment patient outcomes and alleviate the societal burden of concussions and TBI, the application of targeted nutritional interventions warrants further exploration and clinical integration within the field of traumatic brain injury.

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

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

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

Professional experience informs clinical practice. However, exploratory laboratory studies, using relevant models of the human condition, drive innovation in clinical care and neurorehabilitation. Although specific pharmacological treatments have not translated from experimental models to the clinic, the resultant insights, knowledge, and perspectives empower clinical providers to make informed decisions with their patients regarding diagnosis, prognosis, and treatment of TBI. The presentation will discuss investigations that delivered evidence to advance TBI clinical care and neurorehabilitation.

This session was built from submitted abstracts and pairs laboratory with clinical studies to identify and intervene in the treatment of traumatic brain injury. The talks will focus on pain, inflammation, and nutrition as chronic co-morbidities, with mention of mechanisms that can be targeted for therapeutic interventions. The six 12-minute talks will be followed by an integrated and moderated discussion by the panel co-chairs.

OBJECTIVE: This abstract investigates the utility of Photobiomodulation (PBM) for Traumatic Brain Injury (TBI) treatment, aiming to expand therapeutic options beyond symptom management. It presents a synthesis of PBM's biological mechanisms, a compilation of clinical evidence, and an overview of its regulatory considerations.

METHODS AND MECHANISMS: PBM introduces red and near-infrared (NIR) light to targeted tissues, instigating a cascade of mitochondrial and cellular responses conducive to brain healing. This review elucidates PBM's action in modulating the mitochondrial electron transport chain, fostering gene transcription, and stimulating growth factor production. The activity also attenuates the excitotoxicity and inflammation which are characteristic of TBI.

CLINICAL EVIDENCE: Emphasizing clinical outcomes, substantial evidence from recent studies is presented, demonstrating PBM's effectiveness in improving cognitive and behavioral symptoms associated with TBI. Specific improvements in depression, sleep quality, cognitive function, and PTSD symptoms have been consistently reported. Notably, reaction time and grip strength enhancements serve as additional objective metrics of PBM's impact on neural recovery. Additionally, case reports involving former athletes with suspected chronic traumatic encephalopathy (CTE) reveal symptom alleviation in similar domains, reinforcing PBM's therapeutic potential even in a worrying spectrum of brain injuries. The parallels drawn between PBM's effects on CTE and clinical evidence for Alzheimer’s disease underlines a broader application for neurodegenerative disorders.

PERSONALIZATION THROUGH TECHNOLOGY: Recognizing the heterogeneity of TBI, this presentation advocates for the use of artificial intelligence (AI) to personalize PBM treatment. By analyzing individual brain activity through EEG and fMRI, AI algorithms can optimize PBM settings, tailoring the therapeutic regimen to patient-specific neurophysiological profiles.

PIVOTAL TRIAL AND REGULATORY PROGRESS: Looking forward, the presentation details the design of an upcoming multi-site randomized controlled trial (RCT) encompassing 280 subjects to substantiate PBM's efficacy for chronic TBI symptoms. This RCT is a critical step toward obtaining FDA clearance, a milestone that would validate PBM as a sanctioned therapy for TBI.

CONCLUSION: PBM is posited as an innovative, non-invasive treatment modality for TBI, distinguished by its ease of use and potential for integration into home settings. The convergence of promising clinical evidence and ongoing research underscores the need for continued exploration into PBM's capabilities. With AI's advent, the personalization of treatment parameters is anticipated to further enhance PBM's clinical applicability and outcomes in TBI recovery.

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

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

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

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

BACKGROUND: Although safety of coal mine production facilities and regulations continue to improve around the world, gas explosion accidents still exist. Brain damage caused by coal mine gas explosions is a unique type of injury that is different from those that are generally seen by the explosions in wars and open spaces. Specifically, it is caused by the gas explosions from the superposition of repeated shock waves in a closed space and subsequent poisonous gases such as carbon monoxide (CO), which is a particular combination of physical and chemical injuries. Currently, there are many models of simple explosion shock wave or CO poisoning separately, and it was also reported both experimentally and clinically that these injuries do not only cause neurological dysfunction in acute phase, but is also more susceptible to develop neurodegenerative diseases in later stage. However, animal model of coal mine gas explosions with combined injuries does not exist currently, which prevent us from better understanding the difference between the single and combined injuries. We speculate that the combined injuries in coal mine gas explosions are more complex and severe than single injuries. This study will develop an animal model of gas explosion with combined injury by simulating gas explosion condition in coal mine tunnel, and use the model to understand the injury mechanism. We believe that the results will be useful for finding effective intervention methods and early treatments for patients in coal mine gas explosion accidents in the future.

METHODS: 20 adult Kunming white mice were divided into four groups: (1) Single gas explosion (SGE), received one explosion in a customized device; (2) Continuous CO poisoning (CCP), received four CO intraperitoneal injections within 24 hours; (3) SGE+CCP, received single explosion immediately followed by four CO injections within 24 hours; (4) Normal control (NC), received no injury. Behavior tests were performed three and seven days after injuries, then the animals were terminated for molecular biology tests.

RESULTS: The elevated plus maze test shows that in both 3 days and 7 days after injury，all injured groups presented significantly lower entering number when compared to NC group (P < 0.05); while SGE+CCP group also presented significantly lower entering number when compared to SGE and CCP groups (P < 0.05). RT-qPCR test shows that the brain tissues from SGE+CCP group presented significantly higher expression of IL-1β and TNF-α in 3 days after injury as well as higher expression of IL-6 and TNF-α in 7 days after injury when compared to other groups (P < 0.05).

CONCLUSIONS: A mouse model of coal mine gas explosion was developed. The combined injury was found to be more severe than the single injuries behaviourally, which may be related to the more severe inflammation.

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

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

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

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

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

Although there are numerous sequelae associated with concussion, cognitive deficits may be one of the most significant factors contributing to extended difficulties. This session discusses the current recommended practices for assessment and intervention of cognitive management post-concussion, with insights from both neuropsychology and speech-language pathology perspectives. Participants will be able to describe common cognitive deficits post-concussion and identify evidence-based cognitive assessments and treatment approaches for implementation by neuropsychologists and speech language pathologists.

In 2022, the National Association of State Head Injury Administrators (NASHIA) launched its first special interest group, NASHIA’s Collaborative on Children’s Brain Injury (NCCBI). NCCBI’s mission is to improve services and support for children with acquired brain injury. In 2014, NCCBI was formed outside of NASHIA, and in 2023, partnered with NASHIA to expand the group’s impact. NCCBI’s goals include 1) Identifying and addressing critical gaps in the continuum of services and supports, 2) Collaborating with national key partner groups to establish common language, practices, and to make policy/research recommendations, and 3) Educating, sharing information, developing tools, and resources on supports and services. NCCBI has two active working groups. The Standards of Practice workgroup is reviewing documents used across the United States to assess student history of brain injury. The Educational Policy workgroup focuses on early childhood brain injury and examining the processes to qualify for early intervention by state. The NCCBI workgroup’s findings will inform future projects to address the under-identification of children and adolescents who experience brain injury.

The three co-chairs of NCCBI, and colleagues representing school counseling and school psychology, recently submitted a commentary on eligibility determination for school-age children with traumatic brain injury (TBI). This paper explains the public-school evaluation process, including assessment considerations specific to students with TBI. A significant obstacle contributing to the under-identification of students with TBI is that many school districts require a medical statement for a TBI special education eligibility. To remedy this barrier, the authors propose using a guided credible history interview (GCHI) as an alternative to a medical statement. A GCHI is conducted by a school professional who is familiar with a TBI's physical, cognitive, emotional, and behavioral effects and symptoms can emerge over time. The person interviewed is someone with knowledge of the TBI event, such as a parent or guardian. The information provided in the GCHI can then be used by schools instead of a medical statement, increasing the likelihood of identification of students with TBI. In 2020, the state legislature in Oregon adopted the GCHI process. First-year implementation data indicates that the number of students identified under Oregon's TBI special education category increased 21%.

Future research is needed to evaluate the effectiveness of the GCHI to expand the identification of students with TBI so that they receive appropriate learning and behavior support. Students with TBI have nuanced needs that cannot be identified through clinical testing alone. NCCBI will identify and support educational policies that promote expanded use and interpretation of curriculum-based assessments and school-day observation to ensure that investigation of a student’s functional skills occurs where they are likely to show actual deficits.

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

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

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

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

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

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

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

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

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

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

Traumatic brain injury (TBI) is considered a leading cause of acquired disability for children in the US. Despite the high incidence of negative long-term academic, social, and health outcomes for children with TBI, few receive appropriate educational supports. Return to school (RTS) programs have been developed to better assist children with TBI as they return to the classroom. These programs vary widely by state, and no existing RTS program has been systematically evaluated to determine its impact on outcomes for students with TBI. The objective of the School Transition After Traumatic Brain Injury (STATBI) project is to rigorously evaluate the impact of BrainSTEPS, a formal return-to-school (RTS) program, on academic, social, and health outcomes for students in grades K-12 who have experienced TBI of any severity, compared to students who have no formal RTS programming (control arm). STATBI uses a mixed method, cohort-controlled research design. The protocol includes electronic survey administration and virtual interviews with parents and children. This presentation will include data from nine focus groups completed with caregivers from the experimental and control groups during summer and fall 2023. Twenty-five caregivers (100% female) participated in focus groups, with four groups from the control arm and five groups from the experimental arm. The sample included students with mild, moderate, and severe TBI. Questions and discussion focused on how caregivers accessed services, facilitators and barriers to finding care, and their satisfaction with services their child received following TBI. Preliminary analysis of focus group transcripts reveals persistent challenges that caregivers face attempting to find and access necessary supports for mental health and school services for their children with TBI. Caregivers receiving formal RTS support through BrainSTEPS discussed the relief and support provided to them by school-related programming. Caregivers in the control arm discussed persistent difficulties in identifying providers and accessing supports for their children. When supports were identified and provided, unsurprisingly, caregivers were more satisfied with overall service provision. Focus group data is being analyzed further for themes associated with injury severity and time post injury. The STATBI project is unique in its focus on RTS for youth with TBI, and this presentation will describe caregiver perspectives of access to and satisfaction with services for school-age youth with TBI who participate in either formal or non-formal RTS program. Additionally, the sample includes many students who reported having mild injuries but who continued to have academic needs past the typical recovery period that warranted ongoing support services. These findings have important implications for assessing students with TBI as they progress through school. This talk will highlight ongoing study progress and implications for those studying RTS programs for students with TBI.

INTRODUCTION: Social determinants of health (SDoH) include socioeconomic and environmental factors that can influence health outcomes. SDoH are understudied in the concussion literature. Previous research suggests racial/ethnic and socioeconomic disparities in concussion care access. However, whether SDoH are associated with increased likelihood of sustaining a concussion remains unknown. The current study investigated whether SDoH are associated with parent-reported lifetime history of concussion in children and adolescents in a national sample.

METHODS: The 2021 National Survey of Children’s Health is a national survey that collects parents’ self-reported health data on their children. Data from 34,077 youth (ages 5-17) were selected with complete data on the lifetime concussion history survey question. SDoH variables of interest included: primary language spoken at home, family income, parental level of education, and current health insurance. Separate binary logistic regressions were conducted with parent-reported lifetime concussion history as the dependent variable and demographics/SDoH variables as the predictor variables. A multivariable logistic regression was conducted including all predictors in the same model to examine the independence and magnitude of their associations.

RESULTS: In the univariable logistic regressions male sex (OR = 1.4, p < .001), adolescent age (OR = 3.1, p < .001), playing a sport in the past 12 months (OR = 1.9, p < .001), and having current healthcare coverage (OR = 1.5, p < .01) were associated with significantly higher lifetime history of concussion. Hispanic/Latino ethnicity (OR = 0.69, p < .001), non-English primary language (OR = 0.23, p < .001), lower level of parental education (OR = 0.82, p < .001), living in poverty (OR = 0.63, p < .001), and identifying as Black or Asian (OR = 0.55 and 0.31, respectively, p < .001) were associated with significantly lower lifetime history of concussion. In the multivariable model, after accounting for the combined effects of all predictors, significant independent predictors of lower lifetime history of concussion were lower level of parental education (OR = 0.92, p < .05), non-English primary language (OR = 0.36, p < .001), and identifying as Black or Asian (OR = 0.54 and 0.36 respectively, p < .001).

CONCLUSIONS: Several demographic and SDoH variables were associated with lower parent-reported lifetime history of concussion in school-aged children and adolescents including younger age, female sex, Black or Asian race, and Hispanic ethnicity. Adjusting for all variables, lower parental education, not speaking English as the primary language at home, and Black or Asian race were independently associated with lower lifetime history of concussion. Lower health literacy or access to care may contribute to families being less likely to recognize symptoms of concussion or seek out medical care for such an injury.

INTRODUCTION: Previous research has suggested greater lifetime concussion history among children/adolescents with attention-deficit/hyperactivity disorder (ADHD) compared to peers without ADHD. This research has focused on youth athlete’s self-reported ADHD history, as opposed to parent-reported diagnoses, and those studies have not examined differences across broad age spans. It is unclear if ADHD severity or medication status are associated with greater lifetime history of concussion. The current study investigated the association between parent-reported ADHD, ADHD severity, and medication status with lifetime concussion history in a national sample. We hypothesized that parent-reported ADHD severity would be associated with greater parent-reported lifetime concussion history, and that this would not differ across age ranges. We also hypothesized that, among youth with ADHD, those who were taking ADHD medication and those with mild (vs. moderate/severe) ADHD would have lower lifetime concussion history.

METHODS: A sample of 33,914 children/adolescents (ages 5-17, mean = 11 years, SD = 4; 47.9% female) were selected from the 2021 National Survey of Children’s Health (those with complete data on the variables of interest). Overall, 6.2% of youth had parent-reported history of concussion (n = 2,103) and 13.4% had a history of parent-reported ADHD (n = 4,560). ADHD severity (mild or moderate/severe) and medication status (yes/no) were parent-reported for those children/adolescents who had current ADHD. A Mantel-Haenszel analysis was used to assess the associations between ADHD and lifetime concussion history across 5 age groups (5-7, 8-10, 11-13, 14-15, and 16–17-year-olds). Additional Mantel-Haenszel analyses were used to assess the associations between lifetime history of concussion and ADHD severity as well as medication status across the different age groups.

RESULTS: Youth with ADHD were more likely to have greater parent-reported history of concussion across all 5 age bands (χ²Mantel-Haenszel = 80.97, p < .001). However, odds ratios (OR) differed across age-groups (χ²Breslow-Day = 18.48, p = .001). The greatest difference was found in the 5-7-year-old age band (OR = 3.05) and ORs for older ages were smaller (8-10 OR = 1.68; 11-13 OR = 2.04; 14-15 OR = 1.62; 16-17 OR = 1.30). There were no differences in lifetime concussion history for those with mild ADHD versus moderate/severe ADHD (χ²Mantel-Haenszel = 0.02, p = .90). Similarly, there were no differences in lifetime concussion history for those taking ADHD medication versus those who were not taking medication (χ²Mantel-Haenszel = 0.78, p = .38).

CONCLUSIONS: Consistent with previous literature, youth with ADHD had greater lifetime concussion history. Contrary to our hypotheses, this difference was not consistent across ages, as differences between those with and without ADHD were larger for younger children compared to older children and adolescents. Also, among youth with ADHD, parent-reported ADHD severity and medication status were not associated with lifetime concussion history.