7 Effectiveness of synchronous action observation and mental practice on upper extremity motor recovery after stroke
Krystal Robinson-Berta, Nancy Woodsa
aMessiah University, Mechanicsburg, USA
ABSTRACT
Background: Action Observation (AO) and Mental Practice (MP) have historically been researched as independent interventions and demonstrated positive outcomes for motor performance and motor recovery for both healthy individuals and post-stroke patients. MP is documented to improve motor recovery of a hemiplegic upper extremity after stroke, and post-stroke survivors largely retain capabilities to participate in MP interventions. Compared to independent interventions, combined AO/MP activates a larger area of the motor cortex and increases cortical and corticospinal excitability. Although current neuroscience literature recommends combining each modality into one holistic treatment, this method of delivery has primarily been studied with non-stroke samples.
Objective: This quasi-experimental pretest-posttest study examined the effect of a group synchronous AO/MP intervention compared to usual rehabilitation care on upper extremity motor recovery after stroke.
Methods: An a priori power analysis for sample size required 25 participants per group. Fifty-one patients at an inpatient rehabilitation hospital were consecutively assigned to the control (n = 26) or intervention (n = 25) groups. The intervention group received usual care, consisting of a minimum of 3 hours of rehabilitation services per day, 5 days a week, plus group synchronous AO/MP sessions 3 times per week. Outcome measures included the Kinesthetic and Visual Imagery Questionnaire Short Version (KVIQ-10), the Fugl-Meyer Assessment (FMA-UE) of affected upper extremity motor function only and The Box and Block Test (BBT).
Results: Although there were no statistically significant differences in upper extremity motor function between the AO/MP and usual care groups, a subgroup analysis of the intervention group identified statistically significant (FMA-UE: p < 0.001; BBT: p = 0.04) and Minimally Important Clinical Differences on upper extremity motor recovery between patients with behaviors demonstrating more vs. less commitment to the intervention (FMA-UE score > 10: 100% vs. 6.3%; BBT score > 5.5; 66.7% vs. 32.3%).
Conclusion: Group synchronous AO/MP is a promising intervention for patients demonstrating commitment to actively participating in the intervention to improve outcomes on upper extremity motor recovery after stroke. Future studies should include both qualitative and quantitative approaches. Qualitative research to understand the patient’s experience of the group approach and commitment to the intervention would improve our understanding of the patient experience to further develop the intervention. Quantitative studies with larger sample sizes, randomization to groups, psychometrically sound methods to assess patient commitment to the intervention, and an array of videos with options for concordant gender, handedness, and skin tone to individualize the intervention observations are warranted.
8 The prevalence and determinants of neuropsychiatric symptoms in people with acquired brain injury in nursing homes
Roy Kohnena
aLivio, Enschede, Netherlands
ABSTRACT
Introduction: Little is known about neuropsychiatric symptoms (NPS) in the population of patients ≤65 years of age with severe acquired brain injury (ABI) residing in nursing homes. In a systematic review published in Brain Injury, we only found six studies about NPS in patients below the age of 65 years with ABI in long-term care. We found that NPS are common. More insight into the prevalence and determinants of NPS is necessary to achieve appropriate use of psychotropic drugs and promote psychosocial interventions, in particular for patients with ABI ≤65 years of age in long-term care.
Objectives: Establishing the prevalence and determinants of NPS in patients with ABI in nursing homes.
Design: Cross-sectional, observational study.
Setting and Participants: Patients 18–65 years with ABI in special care units in Dutch nursing homes.
Methods: Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the internet. Patient characteristics were collected through digital questionnaires. NPS were assessed with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) and the Cohen-Mansfield Agitation Inventory (CMAI), cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use (PDU) was retrieved from the electronic prescription system. Individual NPS were clustered. Associations between determinants and NPS were examined using multilevel multivariate linear regression models.
Results: In a population of 118 patients from 12 nursing homes, 73.7% had one or more clinically relevant NPS and 81.3% one or more agitated behaviors. The most common NPS were agitation, in particular aberrant motor behavior (24.6%), repetitious sentences/questions (35.5%), and constant requests for attention (34.6%), verbal (33.6%) and physical (50.5%) aggression, and irritability (28.0%). Anxiety and depression were comorbid in 5.1% of the patients. Male patients were more likely to display hyperactivity with a higher score of 3.39 (95% CI 0.70–6.08) compared to female patients. Being married was associated with less verbally agitated behavior (−3.44; 95% CI −6.01, −0.88) and pain was associated with a higher CMAI total score of 6.06 (95% CI 0.22–11.90) Patients with PDU had a higher score of hyperactivity of 3.75 (95% CI 1.23–6.27) and a higher NPI-NH total score of 11.83 (95% CI 6.59–17.07).
Conclusions and Implications: NPS are common in patients with ABI ≤65 years of age residing in nursing homes. This is a first step to fill in the knowledge gap concerning NPS in this population. An increasing number of patients with severe ABI may survive the acute phase and will reside many years in nursing homes. It is important to shed more light on these NPS, with regard to course, magnitude, and severity, to ultimately develop appropriate care for this vulnerable group of patients.
9 The prevalence and determinants of inappropriate sexual behavior in people with acquired brain injury in nursing homes
Roy Kohnena
aLivio, Enschede, Netherlands
ABSTRACT
Introduction: Little is known about neuropsychiatric symptoms (NPS), especially inappropriate sexual behavior (ISB), in the population of patients ≤65 years of age with severe acquired brain injury (ABI) residing in nursing homes. The total number of people with ABI and ISB residing in nursing homes is unknown. Correlates of ISB in this population are unknown as well. Since ISB in ABI is associated with other NPS, it is important to gain more insight into the prevalence rate of ISB, concurrent NPS, and determinants of ISB to promote psychosocial interventions and achieve appropriate use of psychotropic drugs, in particular for younger patients with ABI who will reside in nursing homes for many years.
Objectives: Establishing the prevalence of inappropriate sexual behavior (ISB), concurrent neuropsychiatric symptoms (NPS), and the determinants of ISB among patients with acquired brain injury (ABI) ≤65 years of age in Dutch nursing homes.
Design: Cross-sectional, observational study.
Setting and Participants: Patients 18–65 years with ABI in special care units in Dutch nursing homes.
Methods: Nursing homes were recruited through the national expertise network for patients with severe ABI, regional brain injury teams, and by searching the internet. Patient characteristics were collected through digital questionnaires. ISB was assessed with the St. Andrews Sexual Behavior Assessment, concurrent NPS with the NeuroPsychiatric Inventory-Nursing Home Version and the Cohen-Mansfield Agitation Inventory, cognition with the Mini-Mental State Examination, and activities of daily living with the Disability Rating Scale. Psychotropic drug use was retrieved from the electronic prescription system. Associations between determinants and ISB were examined using multilevel multivariate linear regression models.
Results: In a population of 118 patients from 12 nursing homes, one or more ISBs were present in 38.1% of the patients. Verbal comments (30.1%) and non-contact behavior (24.8%) were the most prevalent types of ISB. Less severe behaviors were more common than more severe behaviors. The most frequent concurrent NPS were verbal agitation (66.7%), physical aggression (61.1%) and hyperactivity (65.1%). Physical aggression was associated with more ISB (0.48; 95% CI 0.22–0.73). Being married (−1.39; 95% CI −2.50, −0.29) and the presence of pain (−3.27; 95% CI −6.27, −0.28) were associated with less ISB.
Conclusions and Implications: ISB is prevalent in patients with ABI ≤65 years of age residing in nursing homes. A satisfying sexual life significantly contributes to overall quality of life and satisfaction. An increasing number of patients with severe ABI may survive the acute phase of ABI and will reside many years in nursing homes. It is therefore important to shed more light on ISB, with regard to magnitude, severity, course, concurrent NPS, sexuality, and quality of life to ultimately develop appropriate care for this vulnerable group of patients.
13 In depth neuroimaging analysis of children with abusive head trauma. can we predict prognosis by acute neuroimaging?
Gunes Ormana, Stephen F. Kralika, Nilesh K. Desaia, Timothy G. Singerb, Sarpong Kwabenac, Sarah Risend, Thierry A. G. M. Huismana
aEdward B. Singleton Department of Radiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, USA, bBaylor College of Medicine, Global Child Health Residency, Texas Children’s Hospital, Houston, USA, cBaylor College of Medicine, Department of Pediatrics, Division of Public Health Pediatrics, Houston, USA, dDepartment of Pediatrics, Division of Child Neurology and Developmental Neuroscience, Baylor College of Medicine, Texas Children’s Hospital, Houston, USA
ABSTRACT
Purpose: Abusive head trauma (AHT) is one of the leading causes of morbidity and mortality in young children. Neuroimaging provides valuable diagnostic and prognostic information, but no single finding is independently able to diagnose or predict outcomes in children with AHT. Our purposes are to describe the prevalence of brain and spine neuroimaging findings, to compare neuroimaging findings with skeletal imaging, and to analyze the association of neuroimaging findings with clinical variables to determine which neuroimaging findings may be used as prognostic indicators.
Materials and Methods: All children clinically diagnosed with AHT between January 2018 and February 2021 were included in this single-center retrospective study. Patient demographics, survival, Glasgow coma scale (GCS) on admission, length of hospital stay (LOS), intensive care unit (ICU) stay and skeletal imaging data were examined. Brain neuroimaging (CT and/or MRI) findings were categorized as 1) classical and 2) “non-classical” findings. Spine MRIs were also assessed.
Results: A total of 102 children (male/female = 75/27), average age 9.49 (range 0.27 to 53.8) months were included. The mortality rate of this cohort was 17.8%. Thirty-six children had only brain CT and 66 children had both brain CT and MRI for neuroimaging evaluation. Subdural hematoma (SDH) was the most common (83.3%) classical, bridging vein thrombosis (BVT) was the most common (30.4%) “non-classical” neuroimaging finding in the entire study population. Interestingly, SDH (72.2%) was the most common classical and BVT (5.6%) was the most common “non-classical” neuroimaging finding when only brain CT was available. Forty-nine spine MRIs were available and spinal ligamentous injury was seen in 49%. No significant difference was found for neuroimaging findings between positive and negative skeletal surveys. Hypoxic ischemic injury (HII) was significantly higher in deceased children (p = 0.0001). GCS was lower if HII (p < 0.0001) and/or spinal ligamentous injury was present (p = 0.017). LOS was longer if intraventricular-hemorrhage (IVH) (p = 0.04), diffuse axonal injury (DAI) (p = 0.017), HII (p = 0.001) and/or arterial stroke (AS) (p = 0.0003) is present. ICU stay was longer if IVH (p = 0.02), DAI (p = 0.01), HII (p < 0.0001), and/or spinal ligamentous injury (p = 0.03) was present.
Conclusion: Neuroimaging is a critical tool in the recognition of AHT. An improved understanding of classical and non-classical neuroimaging findings can inform diagnosis and potentially prognosis. In our study, SDH was the most common (83.3%) classical and BVT was the most common (30.4%) “non-classical” neuroimaging finding but neither of these were related to survival. Mortality was higher if HII was present in the initial neuroimaging. The combination of IVH, DAI, HII, AS and/or spinal ligamentous injury may be used as markers of more severe injury, prolonged clinical course and potential poor prognostic outcome.
33 In the making and telling of a story; a neuropsychological approach to brain injury rehabilitation
Nora Conwaya, Maria Dempseya, Catherine Hold, Jen Galvina, Marcia Wardd,b
aUniversity College Cork, Cork, Ireland, bHeadway, Cork, Ireland, cCork University Hospital, Cork, Ireland, dIndependent Filmmaker, Cork, Ireland
Abstract
This proposal is for a two-part symposium or “special event.” The first part is showing a 23 min long documentary made by people with acquired brain injury about their lived experience as a part of their community neurorehabilitation programme at Headway Ireland.
The second part involves presenting a qualitative research project exploring participants experiences of therapeutic film making.
Purpose: A main goal of brain injury rehabilitation is to support individuals in their holistic journey to recovery post-injury. The holistic model is considered to be the leading approach in the continuity of care for persons with a brain injury as it emphasizes an understanding of the patient’s lived experience from a biopsychosocial perspective. This study considers using documentary-making as a holistic and novel paradigm to support the rehabilitation of people with a brain injury.
As research into the therapeutic benefits of film making on patients with a brain injury is pretty much undocumented, the aim of this study is to evaluate the potential of filmmaking as a transformative and therapeutic tool, as both the process and the product can be used as a medium, to engage in a process of self-discovery, awareness and expression.
Materials and Methods: A qualitative approach using semi-structured interviews was employed with ten project participants; including 7 service users with a diagnosis of non-progressive acquired brain injury, the artistic film director and two staff members; all of whom were invited to share their views and experiences of the project. The data was analyzed using an inductive bottom-up approach to thematic analysis, common threads and patterns were identified and weaved to form a shared narrative of their experiences of the film-making process.
Results: Several themes emerged from analysis of the data that reflect the participants subjective experience of therapeutic filmmaking. Themes are organized based on their cohesiveness into two broad categories, and include the following superordinate themes: mastery, therapeutic alliance, social affiliation, film as catharsis and film as motivation.
Conclusions: The results yielded promising findings in relation to the therapeutic benefits of filmmaking as a medium for transformation and growth.
46 Alcohol motor blocks and neurolysis: case series in two stroke survivors
Tan Yeow Lenga
aSingapore General Hospital, Singapore, Singapore
ABSTRACT
Introduction: Spasticity is a common complication post-stroke and alcohol intramuscular blocks and neurolysis are frequently used as part of the neuro-rehabilitation treatment modalities.
Method: We illustrated two severely impaired stroke cases. Both patients developed spasticity despite physical therapy, declined Botulinum Neurotoxin due to cost concern and subsequently received alcohol treatments for pain relief and ease of care. The first case had bilateral shoulder adductor and elbow flexor spasticity; he received 75% intramuscular alcohol blocks to the Pectoralis Majors and alcohol neurolysis to both musculocutaneous nerves. The second case had left hamstring spasticity leading to pain and difficulty in knee extension for hygiene care. This patient also received 75% alcohol intramuscular blocks to the left hamstrings. Both interventions were conducted under the guidance of bedside ultrasound by experienced rehabilitation physicians.
Results: In Case One, there was significant improvement in Visual Analogue Scale, spasticity of the shoulder using the Modified Tardieu Scale, joint range-of-motion over the shoulders and elbows at both 6-weeks and 3-months. This facilitated better upper body dressing and hygiene care for the caregiver. In Case Two, at 6-weeks and 3-months, there was reduction in spasticity across the left knee during extension, facilitating better hygiene care and sitting posture. Improvement of the left knee pain during ROM allowed better tolerability to stretching exercises during physical therapy. No adverse effects such as bleeding or dysesthesia were reported.
(Note: A table summarizing the outcomes of both patients would be presented if this abstract is accepted)
Conclusions: The use of alcohol of 50 to 100% or phenol of 6 to 12% can be considered as part of the spasticity treatment modalities for selected groups of brain injury patients. Both patients had positive outcomes for pain, joint ROM and ease of care post-intervention. Alcohol treatment for spasticity is low cost, generally safe and can be used as a single pharmacological agent or combined with botulinum toxin when intervening spasticity. A goal-oriented approach should be discussed with patients when deciding the different choices and timings of various chemo-denervation.
48 Acutely worsened dystonia and spasticity following liver transplant in a patient with Wilson’s disease – inpatient rehabilitation and intrathecal baclofen management
Oliver Acostaa, Nicole Ponteea, Joslyn Gobera
aUniversity Of Miami/Jackson Memorial Hospital PM&R Residency Program, Miami, USA
ABSTRACT
Case Diagnosis: Intrathecal Baclofen Management for Severe Spasticity in the Setting of Wilson’s Disease After Liver Transplantation
Case Description: A 20-year-old male diagnosed with Wilson’s disease in August 2020 developed cirrhosis and required orthotopic liver transplantation (OLT) in December 2020. His initial post-operative period went well with improvements noted in his weight and degree of neurologic impairment. However, by September 2021, he developed a significant decline with worsening spasticity and dyskinetic movements, limiting his functional abilities, ultimately requiring hospitalization in November 2021. Despite maximum doses of multiple medications, including baclofen, gabapentin, clonazepam, trihexyphenidyl, and carbidopa-levodopa, these movements persisted. He responded well to an intrathecal baclofen trial and underwent pump implantation in December 2021. Afterward, he was admitted to acute inpatient rehabilitation for intrathecal baclofen management and dosing optimization.
Setting: Inpatient Rehabilitation Following Baclofen Pump Placement and Outpatient Optimization
Assessment/Results: Following baclofen pump placement and inpatient rehabilitation, the patient regained weight, demonstrated improvements in spasticity, and underwent caregiver training for his dependent level of care.
Discussion: Wilson’s disease is an autosomal recessive disorder defined by impaired copper metabolism in which copper deposits in the liver and brain result in the clinical manifestations of liver failure and cirrhosis, and a range of neurological conditions including dystonia, Parkinsonism, seizures, and others. It can be treated medically, but once patients reach hepatic failure, OLT is appropriate, with most cases having improvement in both liver and neurologic manifestations. This case illustrates a rare, acute worsening of a patient’s spasticity with severe functional decline, resulting in the novel application of intrathecal baclofen treatment.
Conclusion: While he continues to require optimization and may benefit from further interventions, such as deep brain stimulation, he experienced significant improvements in spasticity and activities of daily living after intrathecal baclofen pump placement and inpatient rehabilitation.
49 Successful rehabilitation of an infectious brain injury: a rare case of domestic neurocysticercosis
Oliver Acostaa, Gemarayet Alvarez-Gonzaleza
aUniversity Of Miami/Jackson Memorial Hospital PM&R Residency Program, Miami, USA
ABSTRACT
Case Diagnosis: Brain injury secondary to neurocysticercosis
Case Description: A 30-year-old male with no medical history or recent travel presented to the hospital with a 3-day history of left arm shaking followed by generalized shaking of all extremities. MRI Brain showed a centrally necrotic marginally enhancing lesion in the right cingulate gyrus with surrounding vasogenic edema, initially concerning for a glioma. He was started on seizure prophylaxis with Keppra twice a day. Neurosurgery was consulted and the patient underwent a right frontal parietal craniotomy for resection of the lesion. Pathology was positive for neurocysticercosis. The patient subsequently was started on a 2-week course of oral Albendazole and Dexamethasone. He was then transferred to acute inpatient rehabilitation initially requiring maximum to total assistance with mobility, transfers, ambulation and most of his activities of daily living (ADLs). After 12 days, he was successfully discharged, functioning at a minimum assist to supervision level with mobility and transfers and completely independent for ADLs.
Discussion: Neurocysticercosis is the most common form of infectious epilepsy worldwide and is responsible for up to 1/3 of epilepsy cases in highly prevalent areas. It is caused by ingestion of Taenia solium tapeworm larvae usually from undercooked pork. It is relatively uncommon in the United States, however, and it is usually found in patients having recently come from endemic regions. Standard treatment involves anti-helminthics such as Albendazole along with anti-epileptics and steroids to decrease intracerebral inflammation and swelling.
Conclusion: Patients with neurocysticercosis can present to inpatient rehabilitation with many severe motor, language, and cognitive deficits. Combined treatment with consultations from Infectious Disease and Neurosurgery along with interdisciplinary therapy can substantially improve quality of life and lead to significant functional gains during a stay in inpatient rehabilitation.
55 Repetitive peripheral magnetic stimulation for improving upper limb function in post-stroke hemiparesis
Shereen Fawaza, Shin-Ichi Izumib, May M. Farouka, Shaimaa El Dyastya, Heba Gamal Sabera, Amr Saeed Atiaha, Ghada Wassefa, Hossam Labiba
aAin Shams University, Cairo, Egypt, bTohoku University, Sendai, Japan
ABSTRACT
Background: Stroke is one of the leading causes of arm and hand weakness. Repetitive Peripheral Magnetic Stimulation (rPMS) was found to enhance neuroplasticity via its strong muscle contraction and deep proprioceptive stimulation. It stimulates movement in muscles that have lost their central drive, simulating lost voluntary action patterns, resulting in cerebral activation and induction of plasticity. Recent studies reported its effect in increasing cerebral blood flow and reducing spasticity. It can also prevent muscle atrophy, similar to NMES. Hence, it may be considered one of the most effective means of inducing neuroplasticity and enhancing motor recovery, especially in certain groups of patients as acute hemorrhagic strokes, where other modes of neuromodulation as rTMS are potentially hazardous.
Objective: To determine the therapeutic effect of rPMS on the functional improvement of the upper limb in patients with hemiparesis following cerebrovascular insult and to compare the effect of therapy in subacute and chronic cases.
Methods: A randomized double-blinded clinical trial on 80 post-stroke patients, divided into two groups; 40 patients in the control group; received Sham stimulation, and 40 others in the active Group; received Real rPMS. Each group is subdivided into subacute and chronic cases. Its protocol parameters: frequency 30 Hz, Work period 5s, number of trains = 30, a total of 4500 pulses, a session total of 30 minutes on Shoulder abductors, Elbow extensors, Wrist extensors, and Supinator muscles. Sessions were 5 days a week for 3 weeks. All patients received 40 minutes of intensive upper limb training.
Primary Outcome Measures: 1-Fugl Myer (FM) assessment score for the upper limb. 2- Secondary outcome measures: 1- ADLs; FIM score-selfcare section. 2- AROM by goniometry. 3- Spasticity using Modified Ashworth Scale. 4-Ultrasound assessment measuring the cross-sectional area and skin fold (SCT) of extensor digitorum muscle.
Results: Post rehabilitation of all cases compared to controls, the FM score showed significant improvement in all cases (P value 0.010), improvement in the subacute subgroup was also significant (P value 0.028), while non-significant in the chronic subgroup (P value 0.096). AROM showed a highly significant increase in shoulder abduction, elbow and wrist extension, and supination in the active group (P value 0.001). MAS significantly improved spasticity in all cases (P value 0.019). FIM score self-care section showed a highly significant difference in the active group (P value 0.008). U/S measurements showed a non-significant increase in CSA of cases.
Conclusion: rPMS could be an effective means of improving functional motor recovery post-stroke, especially in the subacute stage. It also has the potential of reducing some of the associated maladaptive changes post-stroke as spasticity and muscle atrophy. It could be effective in enhancing recovery in conditions where neuromodulation by rTMS is potentially hazardous as early hemorrhagic strokes.
58 Effects of support dissemination projects for people with cognitive impairment after acquired brain injury, and exploration of qualitative effect indicators
Tamami Aidaa
aMejiro University, Iwatsuki-ku Saitama, Japan
ABSTRACT
Promotion of support projects for people in Japan with cognitive impairment caused by acquired brain injury (ABI) started in 2007. Projects include community consultation (via 254 consultation counters across Japan), support network construction, public relations, dissemination of support, and human resource development. In addition, groups of people with post-ABI cognitive impairment, and their families, are working to support each other in the community. There has now been progress in support for people with post-ABI cognitive impairment, and recognition of their condition has improved, but there has not been enough progress in community integration. The aim of our study was to elucidate effective municipal projects promoting support for social participation by people with post-ABI cognitive impairment. We also aimed to explore qualitative effect indicators of cooperation in the rehabilitation of people with post-ABI cognitive impairment. We conducted a questionnaire survey by mail of 119 consultation counters throughout Japan listed on the homepage of the National Rehabilitation Center for Persons with Disabilities. Counter staff were questioned regarding the implementation status of support projects for post-ABI cognitive impairment, the implementation status of consultations, and qualitative issues of rehabilitation cooperation in the community. The analytical methods used were simple aggregation, frequency distribution, correlation analysis, and factor analysis. Responses were obtained from 59 locations (recovery rate, 49.6%). About half of the respondents had less than 5 years’ experience in supporting people with post-ABI cognitive impairment. There was a strong correlation between the numbers of case study meetings, supporter liaison meetings, and specialized consultations for supporters, and the number of yearly events for associations of people with post-ABI cognitive impairment and their families. There was a strong correlation between the initiation of community rehabilitation and the number of people who returned to, or obtained for the first time, employment. There was also a strong correlation between the number of people who started vocational rehabilitation services and the number who gained employment. Next, we conducted a factor analysis of the results of the project to support, and disseminate support for, people with post-ABI cognitive impairment. From the factor analysis we extracted three factors. The factors were named “multi-layered cooperation,” “achievement of social participation,” and “trends in consultation support.” As the number of consultations increased, the number of people working was expected to increase, and this would therefore promote social participation. In addition, the three factors were considered to be qualitative categories that measured the effects of support projects for those with post-ABI cognitive impairment. To promote community integration of people with cognitive impairment, it is important to ensure hospitals are connected with consultation centers after these people are discharged from hospital.
59 Seeking input from the field on the creation of concussion management program accreditation standards
Terrence Carolana
aCarf International, Tucson, USA
ABSTRACT
As a form of Traumatic Brain Injury, concussions affect an estimated 69 million individuals worldwide and result from a variety of causes including car accidents, falls, sports-related injuries and other forms of trauma. Most individuals who experience a concussion have a resolution of symptoms within one month, however some individuals continue to experience concussion symptoms for a prolonged period of time. Single, multidisciplinary and interdisciplinary concussion management program models exist, however the specific clinical disciplines that provide care to individuals with concussions vary widely across the healthcare spectrum. Additionally, the interventions provided by individual clinicians can vary significantly by type, duration and intensity. As a third-party, nonprofit accreditor of rehabilitation programs, CARF International is collecting feedback from the field of Medical Rehabilitation on recently drafted Concussion Management Program Standards, which will be used to accredit Concussion Management Programs in the future. Based on feedback from all stakeholders, these standards include domains such as education for persons served, personnel and other stakeholders, engagement with post-acute levels of care involved in the treatment of persons served with a concussion, demonstration of knowledge and application of clinical research to treatment practices, provision of or arranging for diagnostic services, prevention of the onset or progression of comorbidities, and wellness. This is not an exhaustive or complete list of domains, and this presentation will be part of CARF’s ongoing efforts to seek feedback from the field on additional domains or content that should be included in these proposed Concussion Management Program standards.
61 Leveraging accreditation to enhance care to persons served across a trauma system continuum
Terrence Carolana
aCarf International, Tucson, USA
ABSTRACT
As countries seek to improve the health and safety of persons served who experience traumatic injuries, developing a comprehensive, nationwide Trauma System has been shown across the world to be an effective strategy to build infrastructure that can manage this care effectively and safely. Person-centered, CARF accreditation standards can be used to support the creation of this new healthcare infrastructure, primarily by giving accredited providers the opportunity to improve quality and performance by demonstrating conformance to accreditation standards and receiving consultative feedback delivered by peers and colleagues from across the field of rehabilitation. By having providers from multiple post-acute care environments approach person-centered care with the same program infrastructure, the consistency of the Trauma System’s approach to care would be enhanced by seeking input from persons served, ensuring accessibility, minimizing risk, developing strategic planning, improving the health and safety of persons served, guiding workforce development and management, and reinforcing the need to develop a culture of performance measurement, management and improvement across business and clinical practices in each specific level of post-acute care. Examples of these post-acute environments of care include Inpatient Rehabilitation, Outpatient Rehabilitation, Home and Community Rehabilitation, Residential Rehabilitation and Telehealth. The Trauma System would also be able to leverage accreditation standards to ensure community engagement by educating the public on both injury prevention strategies and the unique considerations of persons served with traumatic injuries such as Brain Injury. Approaching the care provided to persons served following trauma with person-centered accreditation standards will provide additional quality and performance infrastructure that will ensure the consistency and integration of services across the continuum of the Trauma System.
62 A qualitative international study of social workers’ perspectives on the psychosocial assessment of people with acquired brain injury and their families
Andy Mantella, Kathryn Hyzakb, Lenore Hawleyc, Grahame Simpsone
aAnglia Ruskin University, London, United Kingdom, bOhio State University, Columbus, USA, cCraig Hospital, Englewood, USA, dCalifornia State University, Fresno, USA, eUniversity of Sydney, Sydney, Australia
ABSTRACT
Background: The psychosocial impact of moderate or severe acquired brain injury (ABI) is significant, enduring and complex, affecting the injured individual and family. A comprehensive defined framework for ABI psychosocial assessment does not appear to exist.
Objective: To investigate psychosocial assessment practices among social workers working in rehabilitation and community integration with individuals post-ABI, as an initial step toward development of a comprehensive ABI psychosocial assessment.
Methods: Thematic analysis was conducted on responses to open-ended questions, collected as part of an international survey into psychosocial assessment post-ABI.
Results: A total of 76 social workers from nine countries completed the survey. Respondents had bachelors (26/76, 32.9%) or masters/doctoral (50/76, 65.8%) degrees, working across inpatient (25/76, 32.9%) or outpatient/community (26/76, 32.9%) settings with 11.2 ± 8.9 years’ experience in ABI rehabilitation. Four themes were identified: (i) Difficulty achieving a valid, comprehensive, assessment, for that time, place and remit. (ii) Assessment challenges, which included the complexity of ABI sequelae and comorbidity, evolving clinical profile of the person with ABI, subtle cognitive impairment, and veracity of accounts. (iii) Contextual constraints upon the assessment, from macro-level health and welfare provision to generic and limited local resources. (iv) Strategies to mitigate assessment challenges, comprised communication and engagement techniques and working with families and interdisciplinary teams.
Conclusions: Achieving a valid psychosocial assessment is crucial for the securing of appropriate resources and the desired outcomes for people with ABI’s rehabilitation and community integration. It is a complex, sensitive, process, influenced by national policy, local priorities, access to information, and resource limitations. An ABI specific psychosocial assessment would limit idiosyncratic assessments, provide guidance and disseminate good practice, to ensure that the needs of people with ABI and their families are appropriately met.
63 A community support network intervention to improve quality of life of women with brain injury as a result of intimate partner violence
Shambhu Prasad Adhikaria, Karen Masona, Paul van Donkelaara
aSchool of Health and Exercise Sciences, University of British Columbia, Vancouver, Canada
ABSTRACT
Globally, about 35% of women experience intimate partner violence (IPV) over the course of their lives. Survivors of intimate partner violence often experience violent blows to the head, face, and neck and/or strangulation that result in brain injury (BI). Moreover, survivors of IPV are often exposed to the cumulative effects of repetitive BIs and chronic consequences. Women with IPV-caused BI demonstrate cognitive impairments (e.g., deficits in memory, attention, reasoning, planning and executive functioning), psychopathological problems (such as depression, anxiety, fatigue and post-traumatic stress disorders) and/or sensorimotor problems (such as paralysis or paresis of facial or extremity muscles, numbness, loss of sensation, muscle spasms, facial droop, and unilateral weakness). Neurorehabilitation can be effective in improving physical or cognitive functions and quality of life (QOL) in individuals with BI from other causes but this approach has not been applied before to IPV-caused BI. Therapeutic treatment for IPV-caused BI survivors is crucial, and any physical or cognitive impairment in survivors would require interventions similar to non-partner caused BI to improve QOL and prevent long-term neurodegeneration while also using a trauma-informed approach. One of the primary objectives of the Supporting Survivors of Abuse and Brain Injury through Research (SOAR) Project at University of British Columbia-Okanagan is to characterize changes in QOL, resilience, and neurocognitive functions in women experiencing IPV-caused BI. The pilot study recruited four eligible participants (aged 18–50 years) with IPV-related mild BI through screening from the Kelowna Women’s Shelter. All participants underwent baseline, immediate post-intervention and 6-month post-intervention assessment using various psychopathological, neurocognitive (Cambridge Brain Sciences Neurocognitive testing), resilience (Connor-Davidson Resiliency Scale) and QOL (Medical Outcomes study Questionnaire Short Form 36) measures. The SOAR Community Support Network (CSN) intervention is grounded in a brain injury rehabilitation program developed and powered by ABI Wellness, and in Kelowna delivered by Brain Trust Canada. The program is an evidence-based, multi-pillar, interdisciplinary platform that incorporates aerobic exercise, mindfulness/meditation, counseling, occupational therapy, and cognitive exercises, all of which have been validated and proven to improve function following BI in other populations. The pilot data through descriptive analysis showed that the CSN intervention could be feasibly implemented and led to an improvement in resilience, cognitive functions, and QOL. The expected outcomes of this study will add strong evidence to the feasibility of therapeutic interventions for, and strengthen our understanding of, this understudied experience. Thus, clearly and objectively characterizing the potential for a community support network to improve resiliency, quality of life, and neurocognition will have far-reaching implications for social support policy and funding for this population and their caregivers.
64 Sex differences in concussion characteristics in U.S. service academy cadets: a CARE consortium study
Louise Kellya, Carrie Esopenkob, Jaclyn Caccesec, Scott Andersond, Kristy Arbogaste, Thomas Buckleyf, Sara Chrismang, Jay Clugstonh, JT Eckneri, Stacey Harcumj, Diane Langfordk, Jane McDevittl, Anne Mozelm, Paul Pasquinan, Susan Perkinso, Margot Putukianp, Tricia Robyq, Adam Susmarskir, Elsa Ermers, Kalyn Jannacet, Fransesca Scottu, Christine Masterv, Steve Brogliow, Michael McCreax, Thomas McAllistery
aCalifornia Lutheran University, Thousand Oaks, USA, bIcahn School of Medicine at Mount Sinai, New York, USA, cOhio State University, Columbus, USA, dUniversity of Oklahoma, Norman, USA, eUniversity of Pennsylvania, Philadelphia, USA, fUniversity of Delaware, Newark, USA, gUniversity of Washington, Seattle, USA, hUniversity of Florida, Gainesville, USA, iUniversity of Michigan, Ann Arbor, USA, jUtah State University, Logan, USA, kTemple University, Philadelphia, USA, lTemple University, Philadelphia, USA, mChildren’s Hospital of Philadelphia’s Center for Injury Research and Prevention, Philadelphia, USA, nUtah State University, Logan, USA, oIndiana University, Bloomington, USA, pPrinceton University, Princeton, USA, qThe Center for Injury Research and Prevention Roberts Pediatric Research, Philadelphia, USA, rUnited States Naval Academy, Annapolis, USA, sUniformed Services University of the Health Sciences, Bethesda, USA, tUniformed Services University of the Health Sciences, Bethesda, USA, uUniformed Services University of the Health Sciences, Bethesda, USA, vUniversity of Pennsylvania, Philadelphia, USA, wUniversity of Michigan, Ann Arbor, USA, xUniversity of Wisconsin, Madison, USA, yIndiana University, Bloomington, USA
ABSTRACT
Objective: To describe sex differences in concussion characteristics in U.S. Service Academy cadets
Design: Descriptive epidemiology study
Setting: 4 U.S. Service Academies
Participants: 2209 cadets (n = 867 females, n = 1342 males)
Independent variable: Sex
Outcome measures: Injury proportion ratios (IPR) compared the proportion of injuries by sex (females referent) for injury situation, certainty of diagnosis, prolonged recovery, recurrent injuries, mental status alterations, loss of consciousness (LOC), posttraumatic amnesia (PTA), retrograde amnesia (RGA), motor impairments, delayed symptom presentation, and immediate reporting.
Main Results: Concussions from varsity/intercollegiate sports (IPR = 1.73, 95%CI = 1.43–2.10) and intramurals (IPR = 1.53, 95%CI = 1.02–2.32) accounted for a larger proportion in males; whereas, concussions outside of sport and military activities accounted for a larger proportion in females (IPR = 0.70, 95%CI = 0.58–0.85). The proportion of concussions with prolonged recovery (asymptomatic >14 days or RTP >24 days) was higher in females (IPR = 0.69, 95%CI = 0.60–0.78), while concussions with altered mental status (IPR = 1.23, 95%CI = 1.09–1.38), LOC (IPR = 1.67, 95%CI = 1.17–2.37), PTA (IPR = 1.94, 95%CI = 1.43–2.62), and RGA (IPR = 2.14, 95%CI = 1.38–3.31) accounted for a larger proportion in males. A larger proportion of concussions that were immediately reported was observed in males (IPR = 1.15, 95%CI = 1.00–2.31). Proportions of other characteristics (e.g., recurrent injuries) were not different between sexes.
Conclusions: A higher proportion of concussions occur outside of sport and military training for female cadets, who also displayed proportionally longer recovery times than males, despite males having greater clinical markers (i.e., LOC, PTA, RGA). Possible factors may include different mechanisms of injury outside of sport and military training, different biopsychosocial states associated with sex or injury context, and delayed injury reporting when outside of an observed environment.
65 Health literacy in individuals with traumatic brain injury: characterization and relationship to outcomes in a traumatic brain injury model systems sample
Angelle Sandera, Monique R Pappadisa, Simon Drivera, Anthony Lequericab, John Corrigan, Laura Dreerb
aH. Ben Taub Department of PM&R, Baylor College of Medicine, Houston, USA, bBrain Injury Research Center, TIRR Memorial Hermann, Houston, USA
ABSTRACT
Objective: To characterize health literacy in individuals with traumatic brain injury (TBI), its sociodemographic and injury correlates, and its relationship to health outcomes.
Participants: 205 individuals with medically documented complicated mild, moderate or severe TBI who received inpatient rehabilitation at one of five TBI Model Systems (TBIMS) centers and agreed to complete a health literacy survey after completing TBIMS follow-up at least one year post-injury.
Procedure: Participants completed the Health Literacy Assessment Using Talking Touchscreen Technology (Health LiTT), a multimedia (sight, sound, and touch) self-report measure that was developed using item response theory (IRT) to assess prose, document, and print literacy. This survey was completed online within two weeks of their regular TBIMS follow-up, during which cognition and physical and mental health outcomes were assessed. Data on sociodemographics and injury severity were obtained from the TBIMS national database.
Results: Sixty-nine percent of the sample had adequate health literacy, while 31% demonstrated marginal/inadequate health literacy. The percentage with marginal/inadequate health literacy was more likely to have less than a college education and to be non-Hispanic Black or Hispanic. There were no differences between those with adequate versus marginal/inadequate health literacy with regard to age, sex, and injury severity. Lower scores on the Brief Test of Adult Cognition by Telephone (BTACT) were associated with marginal/inadequate health literacy, for both executive and episodic memory domains. After controlling for age, education, race/ethnicity, sex, injury severity, BTACT scores, and urbanicity, multiple linear regression modeling showed that adequate health literacy was significantly associated with greater physical global health and greater mental global health on the PROMIS Global Health measure. Adequate health literacy was also associated with having a PHQ-9 score that was not indicative of major depressive disorder. Adequate health literacy was not related to having a GAD-7 score indicative of anxiety disorder or to number of physical chronic health conditions. There was a trend (p = 0.09) toward marginal/inadequate health literacy being associated with having at least one chronic mental health condition.
Conclusions: A substantial number of individuals with TBI have marginal/inadequate health literacy, and this is associated with poorer physical and mental health outcomes, even after accounting for sociodemographic characteristics, injury severity, and cognition. Educational interventions to improve health literacy are needed, as well as training of healthcare professionals regarding how to provide information to patients with TBI who may have low health literacy.
67 The impact of complementary and integrative medicine following traumatic brain injury: a scoping review
Marianne Morteraa, Sonya Kimb, Pey-Shan Wenc, Karla Thompsond, Kristine Lundgrene, William R. Reedf, Nicole Sassong, Sarah T. Wrighth, Ariana Vorai, Shilpa Krishnanj, Justin Josephk, Patricia Heynl, Bridget S. Chinm
aDepartment of Occupational Therapy, New York University, NYU Steinhardt, New York, USA, bDepartments of Rehabilitation Medicine and Neurology, New York University Grossman School of Medicine, USA, New York, USA, cDepartment of Occupational Therapy, Byrdine F. Lewis College of Nursing & Health Professions, Georgia State University, Atlanta, USA, dPhysical Medicine & Rehabilitation, University of North Carolina at Chapel Hill, Chapel Hill, USA, eDepartment of Communication Sciences and Disorders, University of North Carolina Greensboro, Greensboro, USA, fSchool of Health Professions, Department of Physical Therapy, University of Alabama at Birmingham, Birmingham, USA, gDepartments of Rehabilitation Medicine, New York University Grossman School of Medicine and Veterans Affairs New York Harbor Health Care System, New York, USA, hUniversity of North Carolina at Chapel Hill, Chapel Hill, USA, iSpaulding Rehabilitation Network and Harvard Medical School, Boston, USA, jDivision of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, USA, kEmory College of Arts and Sciences, Emory University, Atlanta, USA, lCenter for Optimal Aging, College of Health and Education, Marymount University, Arlington, USA, mCollege of Human Medicine, Michigan State University, Grand Rapids, USA
ABSTRACT
Introduction: Rehabilitation programs are progressively incorporating an increase in nonpharmacologic complementary integrative medicine (CIM) offerings to treat persons with traumatic brain injury (TBI). The aim of this scoping review was to examine the evidence levels, study characteristics, and outcomes of nonpharmacologic CIM interventions in rehabilitation for individuals with TBI.
Methods: The following databases that were sourced included MEDLINE (OvidSP), PubMed (NLM), EMBASE (Embase.com), CINAHL (EBSCO), PsycINFO (OvidSP), Cochrane Library (Wiley), and National Guidelines Clearinghouse databases. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was followed to conduct this review, and the study protocol was registered in INPLASY (protocol registration: INPLASY202160071).
The data extraction process involved the review of quantitative studies published between 1992 and 2020 that investigated the efficacy of CIM for individuals with TBI of any severity, age, and outcome. Exclusion criteria included animal studies, studies of special diets, herbal and dietary supplements, counseling/psychological interventions, and mixed samples if TBI data could not be extracted. A two-level review comprised of title and abstract screening, followed by full-text assessment by two independent reviewers, was completed.
Data synthesis was completed through a compilation of data into a single spreadsheet using Microsoft Excel 2019 (Microsoft Corporation, Richmond, Washington) for validation, coding, and data analyses. Data were summarized using descriptive statistics.
Results: Study characteristics: 90 studies were included, with a total of 57,001 patients. Of the 90 studies, 18 (20%) were randomized controlled trials (RCTs). The remainder included 20 quasi-experimental studies (2-group or 1-group pre/post-treatment comparison), 9 retrospective studies, 1 single-subject study design, 2 mixed-methods designs, and 40 case study/case reports. The American Academy of Neurology evidence levels were used to rate included studies. Class II criteria were met by 61% of the RCTs. CIM interventions included biofeedback/neurofeedback (40%), acupuncture (22%), yoga/tai chi (11%), meditation/mindfulness/relaxation (11%), and chiropractic/osteopathic manipulation (11%). Clinical outcomes included physical impairments (62%), mental health (49%), cognitive impairments (39%), pain (31%), and activities of daily living/quality of life (28%). Additional descriptive statistics were summarized using narrative synthesis. Of the studies included for analyses, 97% reported overall positive benefits of CIM.
Conclusion: Positive trends were noted in the majority of studies. There is a need for more rigorous and well-designed studies (including RCTs) to confirm the initial evidence supporting the use of CIM found in the existing literature.
69 Concussions during US Military Service and subsequent diagnoses of dementia, mild cognitive impairment, and memory loss: a career history archival medical and personnel system study (1980–2020)
Jennifer Beldinga,b, James Bonkowskia,b, Robyn Englerta,b, Cynthia Thomsena, Ansley Stanfillc, Jack Tsaod
aNaval Health Research Center, San Diego, USA, bLeidos, San Diego, USA, cUniversity of Tennessee Health Science Center, Memphis, USA, dNYU Grossman School of Medicine, New York, USA
ABSTRACT
Introduction: More than 450,000 members of the US Armed Forces have sustained a TBI since 2000. As this population continues to age, it will be critical to have a thorough understanding of the association between TBI and subsequent neurodegenerative conditions such as dementia. Although research suggests an association between severe TBI and Alzheimer’s disease, limited evidence to date has examined associations between concussion and early onset (i.e., recorded before age 65) Alzheimer’s, related dementias, and precursors such as memory loss and mild cognitive impairment (MCI). The purpose of the present research was to examine whether concussions sustained during active-duty service were associated with these adverse outcomes following retirement from military service.
Method: The Naval Health Research Center’s Career History Archival Medical and Personnel System, a population-level database with a longitudinal record of service members’ career records and diagnoses recorded in TRICARE-reimbursable medical encounters, was used to identify those who served on active-duty between 1980–2020 and were >45 years of age by 2020. The Military Health System Data Repository was used to track medical data following retirement. ICD-9 and ICD-10 diagnoses of interest included mild TBI, Alzheimer’s disease, other dementias, MCI, and memory loss. Logistic and Cox regression analyses regressed early-onset dementia and specific diagnoses (e.g., Alzheimer’s disease, MCI) on concussion while adjusting for relevant military service and demographic characteristics (e.g., occupational risk of low-level blast [LLB]) and previously known risk factors for dementia (e.g., cardiovascular disease). Due to the large sample size, a p < 0.001 threshold was defined as significant.
Results: Of the approximately 6.1 million service members who served on active-duty between 1980–2020 and were > 45 years old by 2020, approximately 1.2 million retired from military service and met inclusion criteria (average age in 2020 = 68). Associations between concussion and early-onset dementias (including but not limited to Alzheimer’s) were inconclusive. Those diagnosed with concussion were more likely to be diagnosed with any dementia (adjusted hazard ratio [AHR] = 1.64), MCI (AHR = 4.44), and memory loss (AHR = 4.14) after retirement, which may include diagnoses before or after age 65. Furthermore, occupational risk of LLB was significantly associated with any dementia (AHR = 1.11) and memory loss (AHR = 1.16).
Discussion: Diagnoses of concussion during active-duty service were associated with a 64% greater risk of being diagnosed with any dementia and a fourfold increase in diagnoses of memory loss and MCI. These findings add to a growing body of evidence supporting the association between concussion and neurodegenerative conditions. It is expected that the prevalence of dementia and corresponding burden to the Department of Veterans Affairs will increase as the >450 K service members diagnosed with TBI between 2000–2020 continue to age.
71 Telehealth administration of narrative and procedural discourse: a United Kingdom and United states comparison of traumatic brain injury and matched controls
Nicole Crusea,b, Victor Piottoc, Carl Coelhob, Nicholas Behnc
aSacred Heart University, Fairfield, USA, bUniversity of Connecticut, Storrs, USA, cCity University London, London, England
ABSTRACT
Background: Impaired discourse production is commonly reported for individuals with TBI. Discourse deficits can negatively impact community integration, return to employment, and quality of life. COVID-19 restrictions have reduced in-person assessment services for people with communication impairments. Advances in telehealth may help SLPs to assess discourse more systematically and improve access to services for patients who may find it difficult to attend in-person.
Aims: The present study examined the feasibility of telehealth administration of narrative and procedural discourse tasks to individuals with TBI and matched controls and compared the discourse performance of both groups from the UK and USA.
Methods and Procedures: Twenty individuals with TBI and twenty healthy controls, ages 18–55, were recruited from the UK and USA. For participants with TBI, time post-injury was at least three months with no diagnosis of aphasia. Control participants were matched for sex and age. Feasibility of measures was based upon time taken to complete assessment and any reported problems. Discourse samples were transcribed verbatim and analyzed using story grammar analysis (for narrative discourse) and identification of propositions (for procedural discourse). Inter-rater reliability was calculated using percent agreement for 50% of the data. Non-parametric analyses were used to analyze the performance of the two groups.
Outcomes and Results: Narrative and procedural discourse samples were collected via telehealth in approximately 10 minutes with no reported technical difficulties or complaints from any participants.
For narrative discourse performance, there were significant differences for the TBI and control groups for measures of complete episodes (p = <0.001) and missing episodes (p = 0.005). No significant group differences were noted for any of the procedural discourse measures. There were some differences for procedural discourse between the US and UK participants.
Conclusions and Implications: Results support the feasibility of collecting discourse samples via telehealth. Although the participants’ discourse performance distinguished the TBI and control groups on the narrative task, no differences between the groups were noted for the procedural task. The narrative discourse task may have been more difficult than the procedural task, or that the procedural task was more challenging for the participants to interpret via telehealth. This finding suggests that alternate modalities or tasks may discriminate groups more clearly for the collection of procedural discourse samples.
76 High-sensitivity C-reactive protein is a predictor of depression in patients with mild traumatic brain injury
Hyun ho Ryua, Eujene Junga
aChonnam National University Hospital, Gwangju, South Korea
ABSTRACT
Introduction: Depression is one of the most common psychological problem after mild traumatic brain injury (mTBI), affects various aspects of life quality. In previous studies demonstrated that systematic inflammation might lead to the unfavorable outcomes including depression after TBI. So, we analyze the relationship between the serum level of high sensitive C-reactive protein (hsCRP), which is sensitive biomarker of systematic inflammation, and depression incidence after mTBI.
Methods: We used the Level-1 trauma center registry between Jan, 2018 to Dec, 2019 in Korea. The population of our study was adult mTBI patients who visit one level-1 trauma center using emergency medical service (EMS) between 2018 and 2020. The main exposure is serum level of hsCRP, which measured just after emergency department arrival. The main outcome was depression, which measured 6-months after hospital discharge using Beck depression inventory. Multivariable logistic regression analyses were performed to estimate the effect sizes of hsCRP on incidence of depression. In addition, interaction analysis was performed between hsCRP and fever on incidence of depression.
Results: A total of 257 mTBI patients were finally enrolled. The multivariable logistic regression analysis showed that elevated serum level of hsCRP was associated with higher odds of depression (aOR (95% CI): 1.34 (1.03–1.69)). The association was maintained only in the fever group (1.42 (1.14–1.78))
Conclusions: Elevated serum level of hsCRP increased the incidence of depression after 6-month of hospital discharge and this effect was maintained significantly when fever was observed. The results of our study are the basis of suggesting the need for strategies for the prevention of depression when there is evidence of systematic inflammation such as CRP elevation and/or fever in mTBI patients.
77 Impact of cervical spine immobilization (CSI) on clinical outcomes in traumatic brain injury (TBI) patients according to prehospital mean arterial pressure: a multi-national and multi-center observational study
Eujene Junga
aChonnam National University Hospital, Gwangju, South Korea
ABSTRACT
Purpose: Cervical spine immobilization (CSI) has been considered an essential part of first aid management after severe trauma; however, the routine use of CSI for traumatic brain injury (TBI) patients is a matter of debate. The purpose of our study was to analyze the effect of CSI on the clinical outcomes of TBI patients and to analyze whether this effect depends on the prehospital mean arterial pressure (MAP).
Materials and Methods: This was a prospective multi-national, multi-center cohort study using Pan-Asian Trauma Outcome Study (PATOS) registry in Asian-Pacific, conducted on adult trauma patients. The main exposure was the implementation of CSI before hospital arrival. The main outcome was poor functional recovery at hospital discharge measured by the modified Rankin Scale (mRS). We performed multilevel logistic regression analysis to estimate the effect size of CSI for study outcomes. Interaction analysis between CSI and MAP on study outcomes were also conducted.
Results: CSI for TBI patients is significantly associated with an increased poor functional outcome (aOR, 95% CIs: 1.23 (1.03–1.44)). The association of CSI with poor functional outcomes was maintained only in patients with decreased prehospital MAP (1.38 (1.14–1.56)), but not in patients with normal MAP (1.12 (0.93–1.24)) (p for interaction<0.05).
Conclusion: Routine use of CSI for patients with TBI, but without cervical spine injury, is associated with poor functional outcomes, but is significant only when the MAP, measured at the scene, was decreased.
78 The positive effect of brain tissue oxygen monitoring on long term outcomes in severe traumatic brain injury
Ondřej Hrdýa, Kamil Vrbicaa, Milos Dubaa, Martin Smrckaa, Roman Gala
aUniversity Hospital Brno and Masaryk University, Brno, Czech Republic
ABSTRACT
Traumatic brain injury (TBI) remains a significant public health burden. Management of severe TBI currently focuses on minimizing secondary brain injury, with particular attention centered on the identification and treatment of elevated intracranial pressure (ICP). However, as secondary brain injury may develop despite normal ICP levels, other parameters might be monitored to enhance patient outcomes. One parameter of interest in this regard is brain tissue oxygenation (PbtO2). However the role of PbtO2 monitoring and its impact on posttraumatic outcomes remains a controversial topic and the results of recent studies remain conflicting. Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard ICP monitoring. In this retrospective cohort study, we analyzed the outcomes of 77 patients with severe TBI who were admitted to Level 1 Trauma Center. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone. Patient demographic data, injury type, clinical data and clinical outcomes were compared between study groups. The values of Glasgow outcome scale (GOS) 30 days and 6 months after injury were compared between study groups. Overall outcome was dichotomized into favorable (GOS 5 or 4) and unfavorable (GOS 1–3). There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or GOS one month after TBI (median GOS 3 in both groups, p = 0.107). However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2 (median GOS 3 vs. 4, p = 0.013). The role of PbtO2-based guidance in the management of TBI remains an unresolved but promising subject for future research. Results of well-designed randomized controlled trials will be needed to clarify the role of PbtO2 monitoring in TBI patients.
79 Right place, right space: housing and supports for people with brain injury to maximize rehabilitation potential and brain health
Grainne McGettricka,b, Hugh O’Connorc
aAcquired Brain Injury Ireland, Dublin, Ireland, bGlobal Brain Health Institute, Trinity College Dublin, Dublin, Ireland, cAnvers Housing Association, Dublin, Ireland
ABSTRACT
Introduction: The experience of working with service providers in the provision of specialist and other housing options highlighted that there is a gap in the knowledge around the specific requirements that maximize the quality of life and the rehabilitation potential of the person with brain injury/stroke) in their home.
Methods: We engaged in research with brain injury survivors to learn from the lived experience of their specific housing needs. We carried out a qualitative survey to learn what were the key housing issues (N = 51). The survey took the form of a facilitated conversation and followed a structured template.
Findings: Brain injury survivors want homes that are inclusive and friendly, alive, accessible and affordable. They want their homes to be attractive and desirable with the ability to meet their sensory needs as well as being sustainable and green. Residential places are environments with permeable skins that protect and regulate diverse internal social ecologies, centered around living patterns and routines that dynamically balance/adapt to individual’s lives and aspirations in harmony and/or counterpoint with others.
A key theme to emerge was that privacy and personal space matters. Those living independently were content (largely in mainstream provision), with some yearning for greater independence or social connectivity. Access to transport services varied as did independent access to activities in the community. There was a clear urban/rural divide with loneliness cited as an issue where social connectivity was difficult. Specific issues to emerge for our addressing attention deficits/visual processing/orientation/filtering noise, helping people adapt/remodel their own homes and the need to preserve a sense of home. High importance was placed on improving connections to community services and removing barriers to isolation.
Findings: Based on our research we agreed the following 4 principles in our approach to housing provision:
The right place: my home is in an area where I can stay locally connected
The right space: my home is designed to meet my needs over my lifetime
The right support: my home supports me to reach my potential and facilitates my rehabilitation and independence
The right to belong: my home is a hearth which is safe, warm and comforting, enabling me to belong.
We see that these key principles are interlinked and form a dynamic and holistic approach to ‘balancing being in place’:
Conclusion: Having completed the research, we now want to illustrate how the agreed principles we have agreed upon to find expression in practice to inform/educate the key stakeholders. We want to interpret the Universal Design Principles as they relate to people with brain injury across the spectrum of housing provision from specialist to mainstream provision.
80 Time matters – the effectiveness and efficiency of specialized intensive inpatient rehabilitation for functional recoveries from disorders of consciousness
Bei Zhanga,b, PhD Katherine O’Brienb,c,d, Jean Wooa,c, Bradley Chib,c, Colton Reehb,c, Sheng Lib,d, Sunil Kotharia,c
aDivision of Physical Medicine and Rehabilitation, Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, USA, bTIRR Disorders of Consciousness Rehabilitation Program, TIRR Memorial Hermann, Houston, USA, cH. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, USA, dDepartment of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA
ABSTRACT
We conducted a retrospective review study to evaluate the effectiveness and efficiency of a specialized acute inpatient rehabilitation program for disorders of consciousness (DoC) using measurable clinical parameters. The cohort contained 137 patients with DoC admitted to the program between January 2014 and October 2018. Patients were categorized as admitted in an acute (≤28 days postinjury; N = 20), subacute (29–365 days following a traumatic brain injury (TBI) or 29–90 days following a non-TBI; N = 84), or chronic (>365 days following a TBI or >90 days following a non-TBI; N = 33) stage. Outcomes included the emergence rate, Functional Independence Measure (FIM), rates of achievements in decannulation and initiation of oral diet, and time to achieve those functions. The cohort contained patients on average of 36-year-old, with diverse ethnic backgrounds and an average case mix index of 2.4 (national average for brain injury 1.3–1.4). There were more TBI patients (60–70%) admitted in acute and subacute stages, while more non-TBI patients (67%) in chronic stage. The emergence rates were 90%, 62%, 18% for patients admitted in acute, subacute, chronic stages, respectively. Among the emerged patients, 100%, 85%, 67% had measurable FIM improvements, respectively; around 60% and 20% in acute and subacute stages required moderate assistance or less (FIM≥3) in transfer/communication/eating/grooming/upper body dressing by discharge from Phase I inpatient rehabilitation (average length of stay 65.3 ± 29.6, 91.7 ± 64.6, 85.8 ± 92.8 days, respectively). The decannulation rates were 94%, 67%, 17% and the oral diet initiation rates were 70%, 23%, 6%, respectively. The time to reach the achievements lengthened as chronicity evolved. There was a weak positive correlation (rs = 0.308, p = 0.009) for decannulation and a strong positive correlation (rs = 0.606, p < 0.001) for oral diet between days since injury on admission and days to the achievement since admission. The results objectively demonstrate functional recoveries of persons with DoC following active management and intensive therapies in an acute inpatient rehabilitation setting. In concert with the 2018 AAN/ACRM/NIDILRR practice guideline for DoC, the results justify the utility of inpatient rehabilitation for persons with DoC as evidenced by their functional improvements measured by and beyond the FIM. Unfortunately, inpatient rehabilitation is often denied by payors referring to the criteria set by the U.S. Centers for Medicare & Medicaid Services, due to the assumption of these patients not making “measurable improvements” or being able to “actively” participate in such programs. In reality, these patients tolerate proactive treatments and benefit significantly from the level of care, intensive therapies, and specialists’ expertise. In conclusion, specialized intensive inpatient rehabilitation is not only crucial but also time-sensitive for functional recovery from DoC caused by various etiologies. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation.
81 Diagnosis of brain injury by modal analysis of the human brain
Jayse Mcleana, Mehran Fereydoonpoura, Professor Mariusz Ziejewskia, Ghodrat Karamia
aNorth Dakota State University, Fargo, USA
ABSTRACT
When the human brain experiences impact, waves of vibration are sent throughout the brain. These waves propagate and attenuate at different rates within the brain depending on the magnitude and direction of loading. Injury is more destructive around the brain’s resonant frequencies with the external applied loading and motion. Like any other dynamic systems, the human brain subjected to vibration exhibits natural frequencies and natural modes of vibration. Any motion on head synchronized with these modal vibrations causes extensive increase in strain and stretching of brain tissue and leads to traumatic brain injury. Most vibrations due to any type of assault on the head are sent throughout the brain under impacts or high motions. By conducting dynamical modal analysis of the brain and identifying its resonant frequencies one can measure the risk of injury and reduce or possibly even eliminate vibrations in the close neighborhood of these frequency ranges. Elimination or change of vibrations usually can be done by head gears or helmets. Although most observations and criteria involving brain injury are focused on acceleration and forces and the brain injury is poorly understood in the frequency domain, however extracting the natural frequencies of brain are efficient tools for this purpose. This paper employs a finite elements method to simulate the impacts for 5 different impact angles on a human head. A numerical technique based on dynamic mode decomposition (DMD) will be used to extract the modal properties for the brain tissue in regions near the corpus callosum and brain stem. Three modal frequencies were identified with frequency ranges of 44–68 Hz, 68–155 Hz, and 114–299 Hz. It was found that the impact angle, displacement direction, and region of the brain have a significant impact on the modal response of brain tissue during any impact.
82 A preliminary longitudinal assessment of shunt surgery for non-acute posttraumatic ventriculomegaly following severe brain injury using 18 F-FDGPET
Tomohiro Yamakia
aRehabilitation Center For Traumatic Apallics Chiba, Chiba, Japan
ABSTRACT
Background: Non-acute posttraumatic ventriculomegaly is observed for patients with severe brain injury, but there are cases in which neurological symptoms are improved by shunt surgery. Previous reports have shown that the cortico-basal ganglia-thalamo-cortical pathway, which controls cognition, sensorimotor behavior, may relate to functional recovery following brain injury. Therefore, we examined the effect of shunt surgery on cerebral metabolism for non-acute posttraumatic ventriculomegaly.
Methods: Of the 65 patients with severe brain injury who were admitted to our hospital from November 2017 to December 2020, 8 patients who underwent shunt surgery for non-acute posttraumatic ventriculomegaly were examined using longitudinal 18 F-fluoro-2-deoxy-D-glucose (FDG) -positron emission tomography (PET). The Coma Recovery scale-revised (CRS-R) was used for neurological assessment. The standardized uptake value (SUV) of the whole brain, thalamus, basal ganglia, and substantial nigra were measured before and after the surgery.
Results: After the shunt surgery, the CRS-R scores of all 8 patients improved during the observation period of approximately 2 years. The SUVs of 3 patients (Rapid group) whose CRS-R score improved rapidly by surgery and 5 patients (Slow group) who recovered slowly were compared using chi-square test and the Mann-Whitney U nonparametric test. The motor function score of CRS-R subscore improved immediately after shunt surgery in all patients of the Rapid group. There were no significant differences in gender, major injury mechanism, or time from injury to shunt surgery between the two groups. On the other hand, compared with SUVs before and after the surgery, glucose metabolism in the left basal ganglia improved immediately after surgery in the Rapid group (2nd-1st SUVmax, p = 0.036; 2nd-1st SUVmean, p = 0.036).
Discussion: The effects of shunt surgery for non-acute post-traumatic ventriculomegaly may be immediate or gradual, but in any case, the overall neurological symptoms were improved. It is possible that the dominant hemisphere is related to the improvement in left basal ganglia glucose metabolism following shunt surgery because language function should be considered while evaluating neurological function.
Conclusion: It was suggested that shunt surgery for non-acute posttraumatic ventriculomegaly may contribute to glucose metabolism in left basal ganglia in terms of rapid improvement the rapid improvement of neurologic symptoms.
83 Life with a cognitive communication disorder – what can be learned from a first person account?
Boudewijn Busa
aGgz Oost-brabant, Boekel, Netherlands
ABSTRACT
Cognitive communication disorders are those in which a person has difficulty communicating because of cognitive dysfunction. It occurs relatively frequent after brain injury and symptoms have a great impact on patients’ lives, as the ability to communicate is central in almost any interpersonal interaction. As a consequence many patients experience difficulties maintaining relationships with relatives and friends.
First person accounts are an educational source for researchers and clinicians to gain insight into first-hand experience of patients with brain injury. In this study a first-person account of a patient with cognitive communication disorders following a vascular brain injury is presented. The account was recorded by the researcher based on an interview to compensate for the communication disorders.
The patient is a former general practitioner who suffered an ischemic cerebrovascular accent in the temporal region of the right hemisphere as a result of carotid dissection. After the initial admission to the hospital he was referred to the local rehabilitation center for outpatient treatment consisting of physiotherapy, occupational therapy, guidance by a social worker and neuropsychological evaluation and treatment. The physical consequences were relatively mild and did not affect functioning, but there were cognitive disorders in executive functioning and communication and mental fatigue. The patient also suffered a depressed mood, compulsive crying, irritability and hypersensitivity for noise and light. Since these latter symptoms remained present after completing the rehabilitation treatment, the patient was referred to a psychiatrist from a tertiary multidisciplinary care center for neuropsychiatry and brain injury, where he successfully received 10 mg escitalopram to treat the compulsive crying, the mood symptoms and the hypersensitivity. A speech and language therapist further examined the communication disorder. The patient was diagnosed with a cognitive communication disorder and he and his wife received psychoeducation.
In the first-person account, the patient describes how the referral to a psychiatric hospital has helped him and his wife. There, the diagnosis of the cognitive communication disorder was discussed more explicitly than previously in the rehabilitation center and they received psychoeducation together. He and his wife felt recognized in their daily struggle to overcome the communication difficulties and the strain that has put on their relation. The patient underscores the importance of involving a speech and language therapist. The partner, being the most important communication partner, was always present during the assessment. This was helpful for the psychoeducation because the partner could see where the patient would make mistakes.
Being a former GP, the patient stresses the importance that physicians recognize the cognitive communication disorders, as previously he was not aware that they could occur after brain injury. A timely diagnosis can prevent consequential damage to social relations.
84 Prediction of Post-Concussive Dimensional PTSD Symptoms Using Multimodal Neuroimaging: A Machine Learning Study
Dr. Benjamin Wade1, Dr. Tate David2, Dr. Naomi Hunsake2, Ms. Carmen Velez2
1Division of Neuropsychiatry and Neuromodulation, Department of Psychiatry, Massachusetts General Hospital, Charlestown, Massachusetts, United States, 2TBI and Concussion Center Department of Neurology, University of Utah, Salt Lake City, United States
ABSTRACT
Introduction: Posttraumatic stress disorder (PTSD) is a common comorbidity of mild traumatic brain injury (mTBI) with an estimated prevalence of 12-20% in Military Service Members and Veterans (SM&Vs). Previous studies have reported on group-level differences in structural and functional neuroimaging profiles in PTSD, however, comparatively few have used multimodal neuroimaging to predict the presence of PTSD symptoms on the individual level. We use machine learning to predict individual severity of PTSD and its dimensional structure using multimodal neuroimaging measures in a large, multisite cohort of SM&Vs.
Methods: Participants (n=877, mean age=39.6±9.6, n=766 males) were SM&Vs enrolled in the Long-term Impact of Military-relevant Brain Injury Consortium- Chronic Effects of Neurotrauma Consortium. SM&Vs with a history of mTBI(s) (n=766) and without mTBI (n=111) underwent MRI and the PTSD Checklist for the DSM-5 (PCL-5). Random forest regression (RFR) models, trained and tested using 10-repeated 10-fold cross validation, were used to predict the PCL-5 total score and its canonical symptom clusters of intrusive symptoms (Cluster B), avoidance (Cluster C), negative alterations (Cluster D), and arousal (Cluster E). Predictive features for the RFR models included estimates of subcortical volumes, regional cortical thickness, white matter diffusivity, and graph theoretic estimates of global connectivity (GC) of cortical parcellations. Multisite neuroimaging data was harmonized using the ComBat algorithm. Permutation testing was used to assess model significance.
Results: The PCL-5 total score (R2=0.02, p<0.01) and PTSD dimensions of avoidance (R2=0.018, p<0.01) and arousal (R2=0.024, p<0.01) were predicted significantly above chance levels. The PCL-5 total score was predicted by connectivity of the right frontal eye fields (FEF), pars orbitalis, and temporal pole and inferior fronto-occipital fasciculus (IFOF) diffusivity. Arousal symptoms were predicted by connectivity of the right pars orbitalis and right FEF along with diffusivity of the right thalamic radiation. Avoidance symptoms were predicted by the left superior parietal lobule curvature and right pars orbitalis connectivity.
Conclusions: Our findings support that neuroimaging-based biomarkers might detect PTSD and that specific symptom dimensions of PTSD might be detected by functional and structural connectivity of unique and overlapping neural circuits. Components of the dorsal attention and frontoparietal networks were particularly predictive of symptom severity. These findings could serve to inform the diagnosis of PTSD using objective indicators rather than more subjective symptom reports. The identification of neural circuits that underlie specific constellations of PTSD symptoms may be used to inform targeted neuromodulatory interventions in the future.
85 Treating social communication difficulties secondary to a traumatic brain injury using both acceptance and commitment therapy (ACT), and social communication skill instruction
Simone Friedmana
aTherapy Spot, Toronto, Canada
ABSTRACT
Background: Acceptance and Commitment Therapy (ACT) is a behavioral intervention that has been used successfully in clients with a Traumatic Brain Injury that focuses on psychological flexibility and values based behavioral change. Psychological flexibility is necessary for successful social communication and in-turn social relationships. It involves skills such as: theory of mind, self-awareness, empathy, filtering of verbal output, problem solving, being mindful of emotions, actions, and environmental influencers. To improve a client’s social-communication secondary to concussion, it is prudent to also target their psychological flexibility as the skills go hand in hand.
Objectives: To use ACT in combination with direct instruction on social communication as a therapeutic technique for improving both psychological flexibility and social communication.
Methods: Fourteen sessions in total were provided. Two sessions dedicated to assessment (pre and post treatment). Twelve sessions dedicated to treatment. The Essential Guide to the ACT MATRIX was used as a model for service delivery and included structured social communication skill instruction. A pre and post treatment questionnaire was completed by the client and an informant to assess for perceived improvement on social communication skills and perceived improvement on social relationships.
Results: The results showed that after 12 treatment sessions, the client showed self-perceived and informant-perceived improvement on social communication skills and relationship. Furthermore, values-based behavior change (i.e., perceived improved social relationships) was noted as per the ACT MATRIX.
86 Can mild traumatic brain injury alter cognition chronically? A LIMBIC-CENC multicenter study
William Walkera,b, Maya O’Neilc,d, Zhining Oue, Terri Pogodaf,g, Heather Belangerh,i,j,k, Randall Scheibell,m, Angela Pressone, Shannon Milesn,o, Elisabeth Wildep,q,m, David Tatep,q, Maya Troyanskayam,r, Mary Jo Pughp,s, Amy Jakt,u, David Cifua,b
aVirginia Commonwealth University, Richmond, USA, bRichmond Veterans Affairs Medical Center, Richmond, USA, cVA Portland Health Care System, Portland, USA, dDept. of Psychiatry and Dept. of Medical Informatics & Clinical Epidemiology, Oregon Health and Science University, Portland, USA, eDivision of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, USA, fCenter for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, USA, gDepartment of Health Law, Policy & Management, Boston University School of Public Health, Boston, USA, hSpecial Operations Command (SOCOM), Surgeon General’s Office, Tampa, USA, iSt. Michael’s Inc., Tampa, USA, jDepartments of Psychology, and Psychiatry and Behavioral Neurosciences, University of South Florida, Tampa, USA, kJames A Haley Veterans Hospital Research Service, Tampa, USA, lMichael E. DeBakey Veterans Affairs Medical Center, Houston, USA, mH. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, USA, nMental Health and Behavioral Sciences Service, James A Haley Veterans’ Hospital, Tampa, USA, oPsychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida, Tampa, USA, pGeorge E. Wahlen Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, USA, qDepartment of Neurology, University of Utah, Salt Lake City, USA, rMichael E. DeBakey Veterans Affairs Medical Center, Houston, USA, sDepartment of Medicine, University of Utah, Salt Lake City, USA, tVA San Diego Healthcare System, San Deigo, USA, uUniversity of California, San Diego, Department of Psychiatry, San Diego, USA
ABSTRACT
While outcome from mild traumatic brain injury (mTBI) is generally favorable, concern remains over potential negative long-term effects, including impaired cognition. This study examined the link between cognitive performance and remote mTBIs within the Long-term Impact of Military-relevant Brain Injury Consortium-Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) multicenter, observational study of Veterans and Service Members (SMs) with combat exposure. All participants enrolled at the time of data abstraction were included for this study if they passed all three cognitive performance validity tests (n = 1,310). Cross-sectional analysis of their enrollment data was conducted using multivariable regression models that adjusted for covariates that could influence cognitive performance including age, estimated pre-exposure intellectual function, PTSD and sleep. Positive mTBI history groups, 1–2 lifetime mTBIs (non-repetitive, n = 614) and 3+ lifetime mTBIs (repetitive; n = 440) were compared to TBI negative controls (n = 256) on each of seven cognitive domains computed by averaging Z-scores of prespecified component tests. Significance levels were adjusted for multiple comparisons. Results showed that neither of the mTBI positive groups differed from the mTBI negative control group on any of the cognitive domains in multivariable analyses (all p-values > 0.05 even before correcting for multiple comparisons). Findings were also consistently negative across sensitivity analyses (e.g., mTBIs as a continuous variable, number of blast-related mTBIs, or years since first and last mTBI). Our findings demonstrate that the average Veteran or SM who experienced one or more mTBIs does not have post-acute objective cognitive deficits due to mTBIs alone. This suggests that a holistic healthcare approach including comorbidity assessment is indicated for patients reporting chronic cognitive difficulties after mTBI(s), and strategies for addressing misattribution may be beneficial. Future study is recommended with longitudinal designs to assess within-subjects decline from potential neurodegeneration.
87 Relation of aerobic activity to cognition and well-being in chronic mild traumatic brain injury; a LIMBIC-CENC study
William Walkera,b, Brennan Wrighta, Chong Zhangc, Renae Fishera, Amol Karmarkera,d, James Bjorka,e, Mary Jo Pughf,g, Cooper Hodgesh,a, Sarah Martindalei,j, Elisabeth Wildek,l,m, Kimbra Kenneyn,o, Scott McDonaldp,a,q, Randall Scheibelr,m, Mary Newsomer,m, Lawrence Cooks
aDepartment of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, USA, bPM&R Service, Richmond Veterans Affairs Medical Center, Richmond, USA, cDivision of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, USA, dSheltering Arms Institute, Richmond, USA, eDepartments of Psychiatry, Pharmacology and Toxicology, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, USA, fVA Salt Lake City IDEAS Center for Innovation, Salt Lake City, USA, gDepartment of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA, hResearch Service Line, Washington, D.C. VA Medical Center, Washington, USA, iResearch & Academic Affairs Service Line, W. G. (Bill) Hefner VA Healthcare System, Salisbury, USA, jDepartment of Physiology & Pharmacology, Wake Forest School of Medicine, Winston-Salem, USA, kGeorge E. Wahlen VA Salt Lake City Healthcare System, Salt Lake City, USA, lDepartment of Neurology, University of Utah, Salt Lake City, USA, mH. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, USA, nUniformed Services University of the Health Sciences, Bethesda, USA, oNational Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, USA, pMental Health Service, Central Virginia VA Health Care System, Richmond, USA, qDepartment of Psychology, Virginia Commonwealth University, Richmond, USA, rMichael E. DeBakey Veterans Affairs Medical Center, Houston, USA, sDepartment of Pediatrics, University of Utah, Salt Lake City, USA
ABSTRACT
Individuals with mild traumatic brain injury (mTBI) often suffer from chronic difficulties with cognition and well-being for which a potential treatment and mitigation strategy is regular aerobic physical activity and exercise (PAE). The objective of this study was to determine the relationship between PAE levels and objective cognitive performance and subjective cognitive functioning and overall well-being in large study cohort with remote mTBI. Study participants were enrolled in the Long-Term Impact of Military-Relevant Brain Injury Consortium – Chronic Effects of Neurotrauma Consortium (LIMBIC-CENC) Prospective Longitudinal Study, a national multicenter observational study of combat-exposed Service members and Veterans. Among the entire cohort available at time of data abstraction (n = 1,573), those with positive mTBI histories who passed effort validity tests (n = 1087) were classified ‘inactive’ (23%), ‘partially active’ (46%), ‘active’ (19%), or ‘highly active’ (13%) based on aerobic PAE level. A series of multivariable regression models were built and analyzed with statistical significance testing correction for the number of outcomes tested. The models included many covariates that may contribute to outcomes, including demographic and clinical (examples PTSD, sleep, pain). PAE was reported on the Behavioral Risk Factor Surveillance System. Preselected primary outcomes were seven well-validated cognitive performance tests of executive function, learning, and memory; the California Verbal Learning Test-II Long Delay Free Recall and Total Recall, Brief Visuospatial Memory Test-Revised Total Recall, Trail-Making Test Part B, and National Institutes of Health Toolbox for the Assessment of Neurological Behavior and Function Cognition Battery Picture Sequence Memory, Flanker, and Dimensional Change Card Sort tests. Pre-selected secondary outcomes were four standardized self-report questionnaires of cognitive functioning, life satisfaction and well-being. Across aerobic activity groups, cognitive performance tests were not significantly different (all adjusted p-value < 0.05). For subjective outcomes, scores were higher with higher levels of aerobic PAE including life satisfaction (p = 0.009 for partially active versus inactive) and overall health status (p < 0.001 for active versus inactive). Exploratory cognitive performance analyses also showed better working memory and verbal fluency with higher aerobic PAE levels. In conclusion, an association between aerobic activity level and the pre-selected primary cognitive performance outcome was not demonstrated using this study sample and methods. However, higher aerobic activity level was associated with better subjective well-being. This supports a clinical recommendation for regular aerobic exercise among persons with chronic or remote mild TBI. Future longitudinal analyses of the exercise-cognition relationship in chronic mTBI populations are recommended.
90 Exploring feasibility and benefits of cognitive exercise post-traumatic brain injury
Therese O’Neil-Pirozzia
aNortheastern University; Spaulding Rehabilitation Hospital, Boston, USA
ABSTRACT
Traumatic brain injury (TBI) is recognized as a chronic health condition that warrants ongoing monitoring/management. Individuals with TBI and their families report cognitive deficits as some of the most devastating and persistent problems that negatively impact their health, function, participation, and quality of life. Evidence supports that cognitive health, function, and quality of life may improve or be maintained years post-injury, reinforcing the need for continued research examining feasibility and benefits of sustained cognitive exercise. The following findings will be presented from a series of author-completed published pilot studies regarding 1) feasibility of, 2) factors impacting, and 3) outcomes from cognitive exercise engagement post-TBI:
In a mixed methods comparison study exploring feasibility and effects of participation in a computerized cognitive exercise program with 14 chronic acquired brain injury (ABI) survivors with moderate-to-severe cognitive impairments (64.5% post-TBI), 50% participated in the program, and 50% did not. While there were no baseline cognitive or life satisfaction differences between groups, the exercise group demonstrated significantly improved posttest performance on standardized assessments of immediate recall (t(10) = 3.40, p = 0.0068) and verbal fluency (t(10) = 2.51, p = 0.0310). Also, unlike the no-exercise group, the exercise group reported improved life satisfaction, and, in some cases, self- and/or other- reported positive impact from exercise program participation on daily function. While feasible for the exercise group to participate in the program, their needs for ongoing daily external cues to initiate and/or complete exercises did not decrease over time.
In a mixed methods study exploring motivational facilitators and barriers to cognitive exercise program engagement with 34 chronic ABI survivors with moderate-to-severe cognitive impairments (73% post-TBI), thematic analysis identified motivational facilitators that included: 1) positive reinforcement for cognitive exercise activity (21%); 2) receipt of education regarding cognitive exercise (21%); 3) group versus individual cognitive exercise (12%); and 4) possession of cognitive exercise goals (12%). Motivational barriers included: 1) absence of cognitive exercise goals (33%); 2) absent structure to consistently engage in cognitive exercise (33%); and 3) lack of positive reinforcement (12%).
Exercise self-efficacy is the confidence one has in their ability to develop and meet exercise goals. In an observational study using an online survey completed by 133 community-dwelling individuals, associations among cognitive exercise self-efficacy, cognitive exercise frequency, challenge, and enjoyment were explored. Those who engaged in cognitive exercise demonstrated greater cognitive exercise self-efficacy. Cognitive exercise self-efficacy ratings were significantly different across challenge and enjoyment conditions (Pearson’s χ2 test, df = 9, N = 133, χ2 = 123.49, p < 0.01), such that the greater the perception of each, the greater the cognitive exercise self-efficacy (p < 0.01). Comparatively, impact of perceived enjoyment on self-efficacy was greater than impact of perceived challenge.
91 Clinical harmony; The ‘OOMPA’ a joint music therapy and neuropsychology approach to assessment of children with acquired brain injury
Rebecca O’Connora, Sarah O’Dohertya
aNational Rehabilitation Hospital, Dublin, Ireland
ABSTRACT
This presentation outlines the rationale and methodology for a unique joint Music Therapy and Neuropsychology approach applied in the assessment of children with acquired brain injury. It will introduce the O’Doherty O’Connor Music Therapy and Psychology Assessment method (OOMPA) which has been developed over the past thirteen years by a Senior Music Therapist and a Clinical Pediatric Neuropsychologist who have a combined total of 50 years of clinical experience.
The OOMPA is an innovative, child-friendly, observation-based assessment method which provides information about a child’s strengths and weaknesses. It explores and identifies whether specific behaviors are present, emerging, or absent. It is a time-efficient and cost-effective means of obtaining rich information about a child which might not be obtained through other assessment methods. This information can be used to inform and focus targeted treatment plans and maximize available therapeutic and/or financial resources.
The OOMPA is carried out jointly by a Psychologist and Music Therapist using a structured Music Therapy protocol. It can be administered with children aged 6 months to 18 years within the context of a wider interdisciplinary assessment.
The OOMPA presents a series of nine musical scenarios which allow the therapists to systematically observe and record a child’s behaviors and responses. Information about the child’s abilities is elicited through observation and interpretation of the child’s musical and non-musical behaviors during the interactive music making. The principle of inferring cognitive functioning and ability based on a child’s responses within a structured scenario is a central element to any assessment method (O’Doherty & O’Connor, 2015). Research shows that Music Therapy interventions provide a sensitive way of assessing any actions made by an individual and present a ‘unique form of diagnostic potential’ (O’Connor and Gray 2022, Gilbertson & Aldridge, 2008). There is increasing evidence demonstrating that the efficacy of Music Therapy as an assessment medium arises from the fact that it enlists disparate brain functions and systems that would not otherwise be simultaneously functioning in unison. Thaut et.al (2016) suggests that music processing engages widely distributed neural networks that are shared with ‘non-musical’ cognitive, motor and language function. The simultaneous activation of multiple brain systems and regions through music can therefore potentially elicit reactions and responses that might not be observed through other assessment methods.
The format of the OOMPA allows for the impact of any presenting deficits to be minimized and for child’s strengths and abilities to be highlighted.
Case studies, video examples and clinical data will be used to illustrate the OOMPA.
92 Integrating creative arts therapy as part of a specialist acquired brain injury neurorehabilitation interdisciplinary programme in a way that supports individual rehabilitation needs and goals
Rebecca O’Connora, Valerie Twomeya
aNational Rehabilitation Hospital, Dublin, Ireland
ABSTRACT
This presentation will detail an innovative, integrated approach to providing access to Creative Arts Therapy (CAT) for children and adults with acquired brain injury. Using the National Rehabilitation Hospital’s (NRH) Quality Improvement (QI) framework a CAT Service has been established providing access to and integration of music and art therapy to specialist rehabilitation.
CATs are evidence-based professions using prescribed art and music-based methods to accomplish individualized clinical goals within a therapeutic relationship. At the NRH CAT’s are integrated within the existing interdisciplinary team (IDT) supporting patients in achieving neuro rehabilitation goals. CAT clinical interventions are designed to effect positive changes in the psychological, communication, physical, cognitive, or social functioning of individuals with acquired brain injury in a neuro rehabilitation setting. Prior to this initiative there was no art therapy and a very limited music therapy provision at the hospital. Feedback from patients, families and staff coupled with analysis of clinical data clearly identified the need and demand for an integrated, specialist CAT service.
Project Aim: For all NRH patients to have access to CAT as part of their comprehensive IDT programme of neuro rehabilitation to support their individual rehabilitation needs and goals.
Project Implementation: Following consultation with patients, families and staff, a person-centered approach utilizing CAT interventions that met patients’ needs, was established. Opportunities to improve patient experience of CAT were identified, including small groups, conjoint IDT treatment and assessment sessions. Staffing resources were put in place on a temporary basis to support the improvement for patients.
Project Outcomes: CAT therapists monitored and evaluated the service using a series of qualitative and quantitative measures, completed by patients, families, and staff. Results indicated 100% of patients ‘strongly agreed’ that receiving CAT intervention enhanced their rehabilitation and patient experience at the NRH. 100% of IDT members ‘strongly agreed’ that CAT contributed to the success of IDT rehabilitation outcomes. Data also indicated an extensive increase in access for patients to creative arts therapies. 66% of all NRH admissions were referred to the service during the project. A permanent CAT service has now been established at the NRH as a result of the project, which is the only hospital CAT service in Ireland. The project also resulted in the permanent employment of an art therapist and an additional music therapist to allow for continued access for patients. The model has been adopted by post-acute and home and community-based healthcare settings in Ireland. The service also received very positive feedback from CARF (Commission on Accreditation of Rehabilitation Facilities). Surveyors stated that ‘The creative use of the CAT service in all programmes to enhance the functional skills of persons served is innovative and demonstrates the person-centred philosophy of care. It is a true interdisciplinary treatment modality.’
93 Factors related to the quality and stability of partner relationships after traumatic brain injury: results of a systematic literature review
Brenda Van Den Broeka,b,c, Sophie Rijnena,c, Annemarie Stiekemab,c, Caroline van Heugtenb,c, Boudewijn Busa,c
aGGZ Oost Brabant, Boekel, Netherlands, bMaastricht University, Maastricht, Netherlands, cLimburg Brain Injury Center, Maastricht, Netherlands
ABSTRACT
Background and Aim: Both the quality and the stability of partner relationships are at risk after traumatic brain injury (TBI). At the same time, having a partner by their side can be of major importance for injured individuals. The latest literature review on partner relationships following TBI, conducted a decade ago, discussed solely quantitative work and noted significant knowledge gaps. The current review updates and expands on this work by providing an overview of the current state of knowledge on factors related to relationship quality and stability following TBI.
Methods: On April 23, 2020, CINAHL, Embase, MEDLINE, Psychology and Behavioral Sciences Collection, APA PsycINFO, and PubMed were searched for literature on factors associated with 1) relationship quality and 2) relationship stability following TBI. English quantitative and qualitative studies investigating factors associated with relationship quality and/or stability following TBI were included. Two reviewers independently assessed eligibility. If consensus was not reached, a third reviewer’s conclusion was decisive. Information regarding study objectives and characteristics, participant demographics, (in)dependent variables, and main findings was extracted. Study quality was rated using the JBI Checklist for Analytical Cross-Sectional Studies and/or the CASP Checklist for Qualitative Research. Both were performed by the lead reviewer and checked by the second reviewer.
Results: Forty-three studies were included, revealing thirty-eight factors related to relationship quality and/or stability. These factors cover injury characteristics (e.g., severity) and all domains of the ICF-model: body functions (e.g., personality changes), activities (e.g., communication), participation (e.g., social dependence), environment (e.g., children), and personal factors (e.g., coping strategies). The quality of the majority of the included studies (91% for cross-sectional studies and 77% for qualitative studies) was rated as moderate to high.
Conclusions: Relationship quality and stability following TBI are found to be related to a multitude of factors, including newly identified factors such as personality changes and dependence. Future research may wish to quantitatively investigate factors thus far only identified in qualitative research, explore possible positive effects of TBI on relationships, study the experiences of same-sex couples, and include the perspectives of both partners with and without the injury.
94 The growing gap: sleep and word learning over time in adults with moderate-severe traumatic brain injury
Emily Morrowa,b,c, Lindsay Mayberryb,c, Melissa Duffa
aDepartment of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, USA, bDepartment of Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, USA, cCenter for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, USA
ABSTRACT
Cognitive-communication impairment is among the most common and costly consequences of moderate-severe traumatic brain injury (TBI). Word learning is a central but largely unexamined aspect of cognitive communication that draws on memory systems routinely impaired after TBI and is critical to a person’s ability to succeed in rehabilitation, academic, and vocational settings. Word learning is an iterative and dynamic process. In many lab-based word learning experiments, participants encode and subsequently retrieve newly learned words in a single session. These designs are inadequate to capture the full dynamic word learning process over time, making them less ecologically valid. They also limit investigation of the role of behavioral factors, like sleep, in the learning process. Here, we examined word learning over time and the influence of sleep on short- and long-term word recall in 50 adults with chronic moderate-severe TBI and 50 demographically matched neurotypical peers. We used a randomized within-participant crossover design to assess immediate encoding of new words and consolidation of those words over time.
Participants completed this study over the course of two weeks in their own homes to capture the iterative, dynamic process of real-world word learning. Learning and test were spaced so that each participant was tested on newly learned words after intervals when they had slept and after intervals when they had not. We measured sleep in free living conditions using actigraphy. Participants with and without TBI remembered more words when they slept after learning than when they did not. However, participants with TBI exhibited a striking word learning deficit across domains. Critically, this deficit grew over time. Regardless of sleep, the performance gap between groups was larger one week after learning than immediately after learning, suggesting deficits in both encoding and consolidation of new words for individuals with TBI. These results highlight the importance of identifying people at risk for word learning deficits after TBI and developing word learning interventions to both improve immediate performance and mitigate growing performance gaps over time. Ecologically valid research designs that examine the relationship between memory, sleep, and word learning over time promise to advance mechanistic accounts of word learning and improve the long-term retention of new words in individuals with and without brain injury.
95 Moving forward: a case report on the successful treatment of movement disorder after anoxic brain injury
Alyssa Volmricha, Gemayaret Alvareza
aJackson Health System/University of Miami, Miami, USA
ABSTRACT
Case Description: 32-year-old female with type I diabetes and polysubstance abuse presented after being found unresponsive. Her clinical picture was consistent with anoxic encephalopathy and MRI was suggestive of diffuse metabolic injury. She was subsequently admitted to rehabilitation but abnormal eye movements were noted and seizures were diagnosed via electroencephalogram. She was transferred to neurology for optimization of anti-epileptics and was treated with levetiracetam and lacosamide. Subsequent electroencephalogram was negative for seizure activity and she was readmitted to rehabilitation. On re-admission, she had large amplitude, low-frequency, purposeless, restless, suppressible movements left upper and lower extremity. The movements evolved to her right lower extremity. Seizures were ruled out. Despite benzodiazepines, antiepileptics, and opioids, the movements persisted limiting her participation in rehabilitation and distressing her caregivers. Aripiprazole daily was initiated and movements decreased slightly. It was increased to twice daily and movements significantly improved. Patient was discharged home safely.
Discussion: Aripiprazole has complex pharmacology with affinity for multiple dopaminergic and serotonergic central nervous system receptors. It is thought to act as a dopamine D2 receptor partial agonist, a serotonin 5-hydroxytryptamine 2A (5-HT2A) receptor antagonist, and a partial agonist of the serotonin 5-hydroxytryptamine 1A (5-HT1A) receptor. This unique mechanism of action may be why there are conflicting reports in the literature regarding aripiprazole and movement disorders. Aripiprazole has been successfully used to treat tardive dyskinesia, hyperkinesias of Huntington’s Disease, and involuntary movement symptoms with major depressive disorder. This appears to be the case report of successful treatment of akathisia after anoxic brain injury with aripiprazole.
Conclusion: Aripiprazole may be an appropriate agent to use in patients with refractory movement disorders disrupting quality of life and ability to participate in therapy. Further research is needed to determine the exact mechanism of action and safety profile of using aripiprazole for such disorders.
96 A maddening diagnostic dilemma: a case report of Creutzfeldt – Jakob disease in acute rehabilitation
Alyssa Volmricha, Gemayaret Alvareza, Lorenzo Diaza
aJackson Health System/University of Miami, Miami, USA
ABSTRACT
Case Description: 46-year-old male presented with several weeks of worsening vision, headache, neck pain, and altered mental status. At an outside hospital, he was worked-up, diagnosed with meningoencephalitis, and treated with steroids, antivirals, and antibiotics. He was discharged with intravenous antibiotics and plan for follow-up once all diagnostic results returned. However, soon after discharge, he suffered a seizure-like episode and was brought by family to our tertiary institution were encephalitis work-up was inconclusive. Given his deficits, he was transferred to acute rehabilitation. After several days, we were notified by original outside hospital that cerebral spinal fluid results returned and were consistent with sporadic CJD. Due to the gravity of the diagnosis, neurology and infection control were contacted and recommendations provided. Based on limited treatment options and poor prognosis, goals were adjusted to focus on caregiver training. He gradually declined becoming increasingly non-verbal and unable to follow commands. He was discharged with Hospice.
Discussion: CJD has a global incidence of approximately one person in every one million annually. It is caused by conformational changes of normal cellular proteins, found mostly in the nervous system, into abnormal infectious proteins called “prions.” The accumulation of prions is theorized to cause damage to neurologic structures. To our knowledge, there are very few case reports of CJD in acute rehabilitation and even less data available about CJD diagnosis being given after transfer to inpatient rehabilitation where family and therapy had to be educated and goals adjusted accordingly.
Conclusion: CJD is a rare but serious diagnosis that should be considered in young, relatively healthy patients presenting with altered mental status. Rehabilitation goals are fluid and related to diagnoses and prognosis. An interdisciplinary approach can be used to help ease transition from restorative to more supportive management.
98 The challenges of behavior analytic interventions for individuals who require aphasia treatment in a neurorehabilitation setting following an acquired brain injury
Natasha Sinnotta
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland
ABSTRACT
Aphasia effects the verbal behavior of individuals who have acquired a brain injury through many mechanisms such as a stroke, trauma, infection, tumors, or disease. Approximately 50,000 people in Ireland have aphasia and the effects surpass verbal behavior, as social, professional, material, and educational skills are hugely affected. Although there is considerable research by behavior analysts on language assessment and training for individuals with developmental difficulties, the behavior-analytic training in neurorehabilitation settings is almost non-existent. This study begins with a literature review of the works of Skinner and Sidman identifying their significance in forming a behavioral concept of aphasia for behavior analysts to gain an understanding and knowledge of the appropriate treatments to put in place. Skinners 1957 work verbal behavior offers a practical framework for studying aphasia where Skinner references aphasia as an example and demonstrates the functional independence of verbal operants. Sidman in the 1970s provided an analysis of stimulus-response relations and his experimental work on aphasia. Also, Sidman and his colleagues present an exceptional basis for creating a measuring tool for stimulus response relation deficits and so too does Sundbergs contribution to the functions of language. A critical evaluation has identified the barriers that behavior therapists in Ireland are challenged with in treating individuals with aphasia in a neurorehabilitation. The critical evaluation will also discuss the behavioral treatments for aphasia that are combined with speech and language therapy and will critically examine the inconsistencies of this approach. The study closes with consideration of the research which supports the constructive collaboration of behavior therapy and speech and language therapy in devising effective assessment and treatment plans.
99 Current perspectives and practices of dutch speech therapists regarding friendships after brain injury
Sophie Rijnena, Brenda van den Broeka, Mariëlle Reijbroeka, Boudewijn Busa
aGGZ Oost Brabant, Multidisciplinary Specialist Center for Brain Injury and Neuropsychiatry, Boekel, Netherlands
ABSTRACT
Background: Consequences of acquired brain injury (ABI), including social communication problems, negatively affect friendships. However, current speech pathology practices regarding friendships after ABI remain unknown. The aim of this study was to monitor perspectives, practices and facilitating as well as limiting factors with regard to these practices of Dutch speech therapists regarding friendships after ABI.
Method: Survey study on whether, why, and how speech therapists do (not) perform work on friendships after ABI.
Result: Up to 90% of the 36 participating speech therapists believes that work related to friendships after ABI falls within the scope of their responsibilities. 78% of the speech therapists actually performs such activities. The most frequently mentioned facilitating factor in activities regarding friendship is the presence of supporting material, e.g. educational modules. The most commonly reported barriers were very limited social networks to work with and persons with ABI choosing not to involve friends.
Conclusion: Work activities by speech therapists regarding friendships after ABI are numerous. Speech therapists are in need of material that can be used to support their work on friendships. Furthermore, reported barriers in working with friends may be explained by social communication problems. Results of the current study provide us with tools for future work on friendships after ABI with the aim of providing knowledge and resources that can be of help in clinical practice.
100 Return to driving after moderate-to-severe TBI in the United States
Thomas Novacka, Yue Zhanga, Richard Kennedya, Thomas Bergquistb, William Walkerc, Lisa Rapportd, Laura Dreera, Charles Bombardiere, Yelena Goldinf, Candy Tefertillerg, Thomas Watanabeh, Elaine Mahoneya, Jennifer Marwitza, Robert Brunnera
aUniversity Of Alabama At Birmingham, Birmingham, USA, bMayo Clinic, Rochester, USA, cVirginia Commonwealth University, Richmond, USA, dWayne State University, Detroit, USA, eUniversity of Washington, Seattle, USA, fJFK Rehabilitation Institute, Edison, USA, gCraig Hospital, Denver, USA, hMoss Rehab at Elkins Park/Einstein Healthcare Network, Elkins Park, USA
ABSTRACT
Return to driving after a moderate-to-severe traumatic brain injury (TBI) is a common goal for those experiencing TBI. Those who drive report greater community involvement, greater life satisfaction, and fewer symptoms of depression. Information regarding who returns to driving, when that occurs, patterns of driving, and crash risk among persons with TBI has been sparse, particularly for large, well-defined samples. The TBI Model System provided an opportunity to address this gap.
Methods: Enrollees in the TBIMS program completed a driving survey at the conclusion of a scheduled follow-up interview. For the cross-sectional component, a survey was completed on one occasion between one and 30 years after injury (N = 706). For the longitudinal component, participants completed a pre-injury survey and were surveyed at one and two years post injury (N = 334).
Results: Based on the cross-sectional component, 78% of respondents had driven at some point after the TBI, although 14% were not able to maintain driving. At the time of the interview 67% were driving. Return to driving occurred within 2 years for 92% of current drivers, with 42% driving within 6 months of injury. Multiple regression analysis indicated significant differences between drivers and non-drivers with respect to employment, family income, race, seizures, and severity of injury. Most respondents reported driving daily, although 41% indicated driving less than before the TBI. Based on self-report of crash incidence most reported having no crashes, with half of those reporting crashes experiencing one event. Comparing this group to national statistics, those with TBI were 1.5 to 2.5 times more likely to experience a crash. Multiple regression demonstrated that age at survey, years since injury, and perception of driving skills were associated with crash experience. The longitudinal sample indicated 70% had returned to driving within two years of injury. Driving after TBI was less frequent and involved fewer miles per week than reported driving patterns pre-injury. Almost 15% of the sample indicated having experienced a crash (other than the one that caused the TBI) in the year before injury, far exceeding the general population.
Conclusions: Most people after moderate-to-severe TBI return to driving, usually within two years of injury, with a sizable proportion doing so within 6 months. Return to driving is strongly associated with financial status. Even though driving is less frequent after TBI, the frequency of self-reported crashes exceeds what would be anticipated for the general population. However, persons with TBI may be more prone to crashes even before the injury, raising doubt about the validity of comparing this population to the general population, at least with respect to crash risk. This study underscores the need for assessment of driving skills to promote safe return to driving.
101 Development of a virtual reality test of social cognition
Martin Matrea,b, MA Truls Johansena,c, PhD Sveinung Tornåsa, PhD Anne Catrine Trægde Martinsena,c, Frank Beckera,d, Alexander Olsene,f, PhD Skye McDonaldg, PhD Joke Spikmanh,i, Jennie Ponsfordj,k, Marianne Løvstada,b
aDepartment of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway, bDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, cDepartment of Life Sciences and Health, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway, dDepartment of Physical Medicine and Rehabilitation, Institute of Clinical Medicine, University of Oslo, Oslo, Norway, eDepartment of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway, fDepartment of Psychology, Faculty of Social and Educational Sciences, Norwegian University of Science and Technology, Trondheim, Norway, gUniversity of New South Wales, School of Psychology, Kensington, Australia, hDepartment of Neurology, Subdepartment of Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands, iDepartment of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands, jTurner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Richmond, Australia, kMonash-Epworth Rehabilitation Research Center, Epworth Healthcare, Richmond, Australia
ABSTRACT
Background: Impaired social cognition is common after acquired brain injury and is a great burden to patients and their families. There are few standardized tests of social cognition and most have poor ecological validity, i.e. lack relevance to real life functioning. The Awareness of Social Inference Test (TASIT) is among the few available standardized tests of social cognition. TASIT require patients to interpret nonverbal cues from videos of social interactions and consist of three subtests assessing emotion perception and Theory of Mind. The ecological validity of TASIT is challenged by low social presence, i.e. sense of “being there,” as watching videos on a computer screen reduces the user to a third-party observer. In contrast, Virtual Reality (VR) technology facilitates a sense of participation and immersiveness, through realistic three-dimensional graphics and elimination of outside stimuli.
Objectives: To develop and test a VR-version of TASIT that is ready for clinical validation in patients with acquired brain injury, with identical structure and task requirements to the original test. Subgoals have been to produce high quality VR-stimulus materials, and to develop and implement an application that runs the test on VR hardware.
Methods: Material from the original TASIT was translated to Norwegian. Some scenes required modernization and cultural adaptation, but the content and duration was generally preserved. A professional VR film director led the production. Eight professional actors were casted, four men and four women. A clinical neuropsychologist was present on set to ensure that the actors displayed appropriate social cues. Naturalistic locations were used to increase ecological validity and maximize the immersive properties of VR. A 360-degree VR camera was used in the production. 2D and 3D versions of the same videos were produced, allowing for empirical determination of VR TASIT’s immersive properties. A VR application was developed to run the test on commercially available desktop and VR hardware. Responses are provided with VR controllers in the VR version and mouse in the desktop version. Results are stored digitally and are easily extracted from the application.
Results: A Norwegian VR version of TASIT was developed. It is hypothesized that it will induce a greater sense of social presence than the original test. Pilot data (performance, perceived social presence in VR and desktop versions as well as reported adverse events due to cybersickness) from healthy subjects and patients with acquired brain injury will be presented, and stimulus material will be demonstrated.
Conclusion: VR-TASIT has been developed, but its immersive and psychometric properties have yet to be established. Test validity and reliability will be established. Ecological validity will be empirically determined by how well the test predicts self and informant reported everyday social functioning. If psychometrically sound, norms will be developed for clinical use.
103 Self-reported symptomology following single and repeated high-level blast and occupational risk of low-level blast: a millennium cohort study investigation
Jennifer Beldinga,b, Claire Kolajaa,b, Rudolph Rulla, Daniel Tronea
aNaval Health Research Center, San Diego, USA, bLeidos, Inc., San Diego, USA
ABSTRACT
Introduction: Military service members may be exposed to blast including high-level blast (HLB) from incoming munitions (e.g., improvised explosive devices) and low-level blast (LLB) from outgoing munitions (e.g., from firing the Carl Gustav recoilless rifle). Injuries associated with HLB include traumatic brain injury and traumatic amputations, although improvements in personal protective equipment have increased survivability. Those who survive may experience another HLB, but it remains unclear whether repeated HLB exposure is associated with more severe outcomes than single HLB exposure, particularly with regard to subclinical symptomology. LLB has also been associated with subclinical symptomology (e.g., headaches, memory problems). The purpose of the present research was to examine the association between single and repeated HLB and repetitive LLB on self-reported recent (i.e., in the last 4 weeks) and persistent (i.e., in the last 3 years) subclinical symptomology among Millennium Cohort Study (MCS) participants.
Method: The MCS, the largest and longest-running prospective health study of U.S. service members, collected data from 201,619 participants across four panels (recruited 2001–2013) representing all branches of service, components, pay grades, and military occupational specialties. The 2011–2013 survey asked respondents if they had ever been injured by a “blast/explosion/bullet”; if so, they reported the total number of injuries. Participants were categorized as reporting no, single, or repeated HLB exposure. Occupational risk for LLB was ascertained using self-reported military occupation as a proxy. Outcomes of interest were self-reported recent or persistent symptoms newly reported on the 2011–2013 survey. Participants indicated whether they had been bothered by any of 14 symptoms within the last 4 weeks (e.g., headaches, ringing in the ears) and whether they had persistent or recurring problems within the past 3 years for 18 different symptoms (e.g., severe headache, confusion, chest pain). Self-reported new-onset symptoms were regressed on effects of single and repeated HLB (with no HLB exposure as the referent), and occupational risk of LLB and two-way interactions of these exposures were estimated using logistic regression.
Results: Single and repeated HLB (vs. no HLB) were associated with elevated odds of all newly reported symptoms. Repeated HLB was associated with greater risk than single HLB for all 14 recent symptoms and 5 persistent symptoms (i.e., headaches, fatigue, forgetfulness, confusion, and night sweats). Occupational risk of LLB was associated with 4 recent symptoms (e.g., ringing in the ears) and 8 persistent symptoms (e.g., confusion, forgetfulness). Significant interactions of repeated (vs. no) HLB and LLB emerged for both recent and persistent headaches.
Discussion: This research suggests that blast exposure (including HLB and LLB) is associated with recent and persistent subclinical symptomatology.
Disclaimer: Rudolph Rull and Daniel Trone are employees of the U.S. Government. This work was prepared as part of their official duties.
105 Reading in college students with mild traumatic brain injury
Yalian Peia, Katy O’Briena
aUniversity of Georgia, Athens, USA
ABSTRACT
One in seventy-five college students sustains at least one mild traumatic brain injury (mTBI) each academic year. Individuals with TBI, including mTBI, tend to have difficulties with passage comprehension and reading rate, along with reporting reading to be effortful. As reading is fundamental to students’ academic success, contributors to reading difficulties should be better understood to support student learning after injury. Limited studies have examined changes in socio-emotional processing toward reading following TBI, despite close relationships between actual reading performance and self-efficacy, motivation, and self-regulation. Therefore, the current study examined reading self-efficacy sources, reading habits, and associations between reading self-efficacy and reading performance in college students with and without mTBI. We distributed a survey that included consent, eligibility, a reading habits inventory, the College and University Student Reading Self-Efficacy Scale, the Post-Concussion Symptom Scale, the Convergence Insufficiency Symptoms Survey, and the College Academic Self-Efficacy Scale to college students. A subset of survey participants agreed to also complete the Nelson Denny Reading Comprehension Test. We received 1587 eligible responses from neurotypical students and 229 from students with mTBI. Background characteristics, including age, sex proportion, ethnicity composition, class standing, and current GPA were balanced between students with and without mTBI. Most participants sustained a mTBI from sport and recreation related activities (n = 122), followed by fall (n = 44), motor vehicle accidents (n = 30), and hit (n = 29). About 36% had sustained multiple mTBIs, and 30% reported loss of consciousness. Most participants were over 3 months post injury, with the mean time post onset being 4.8 years. There were no differences in daily reading habits between groups, where students were more likely to read e-mails, texts, and social media on a daily basis, followed by assignments and lecture notes. Students usually read fiction and nonfiction novels using physical copies and complete other types of reading activities on a screen. Despite similar needs for daily reading and reading for school, students with mTBI showed lower reading self-efficacy than neurotypical students (p = 0.005). When subscale scores were examined, students with mTBI tended to feel less enjoyment (F(1,1813) = 11.56, p < 0.001) and report more physiological symptoms (F(1,1813) = 29.97, p < 0.001) in reading. Overall current concussion symptom severity (β = −0.33, p < 0.001, R2 = 0.10) and convergence insufficiency symptoms (β = −0.49, p < 0.001, R2 = 0.24) were negatively associated with reading self-efficacy of students with mTBI. In contrast, reading self-efficacy was positively correlated with age (β = 0.14, p = 0.03) and general academic self-efficacy (β = 0.16, p = 0.02). Lastly, reading self-efficacy demonstrated strong and positive correlations with general reading ability (β = 0.74, p = 0.009, R2 = 0.50), vocabulary (β = 0.65, p = 0.03, R2 = 0.35), and text-level reading rate (β = 0.67, p = 0.02, R2 = 0.39). Results suggest that concussion symptoms, especially oculomotor disruptions, may trigger changes in reading self-efficacy post-mTBI. Decreased reading self-efficacy may further affect reading performance and attitudes toward reading, even in those with remote history of mTBI.
106 Ballistic resistance training improves mobility more than usual physiotherapy intervention following traumatic brain injury: a randomized trial
Gavin Williamsa,b, Leanne Hassettc, Ross Clarkd, Adam Bryantb, Meg Morrise,f, John Olvera, Louise Adac
aEpworth Hospital, Richmond, Australia, bThe University of Melbourne, Carlton, Australia, cThe University of Sydney, Sydney, Australia, dUniversity of the Sunshine Coast, Sippy Downs, Australia, eThe Victorian Rehabilitation Center Healthscope & Academic and Research Collaborative in Health (ARCH), Melbourne, Australia, fLa Trobe University, Bundoora, Australia
ABSTRACT
Background: Ballistic resistance training, targeted to the primary lower-limb muscle groups responsible for forward propulsion, implemented in accordance with the American College of Sports Medicine guidelines for resistance training, is a promising new intervention for people with mobility limitations.
Aim: To determine, in people recovering from traumatic brain injury (TBI), is a 3-month ballistic resistance training program targeting three lower-limb muscle groups more effective than usual physiotherapy care for improving mobility?
Design: A prospective, multi-center, randomized controlled trial conducted according to the CONSORT guidelines. Trial registration: ACTRN12611001098921.
Participants: 144 people with mobility limitations as a result of TBI.
Intervention: For 12 weeks, the experimental group had three 60-minute sessions of usual physiotherapy care per week replaced by ballistic resistance training. The control group had usual physiotherapy care of equivalent time consisting of balance exercises, lower limb stretching, conventional strengthening exercises and cardiovascular fitness training. Both groups received gait training.
Outcome Measures: The primary outcome measure was mobility quantified using the High-Level Mobility Assessment Tool (HiMAT). Secondary outcomes were walking speed, strength, balance and quality of life. Outcomes were measured at baseline (0 weeks), after completion of the 12-week intervention (12 weeks), and 12 weeks after the cessation of the intervention (24 weeks).
Results: After 12 weeks of ballistic resistance training, the experimental group scored 3 points (95% CI 0 to 6) higher on the 54-point HiMAT than the control group and they remained 3 points (95% CI – 1 to 6) higher at 24 weeks. Although there was a transient decrement in balance at 12 weeks in the experimental group, the interventions had similar effects on all secondary outcomes by 24 weeks. Participants with a baseline HiMAT <27 gained greater benefit from ballistic training: 6 points (1 to 10) on the HiMAT.
Conclusion: This randomized trial shows that ballistic resistance training has a similar or better effect on mobility than usual physiotherapy care in people with TBI. It may be better targeted toward those with more severe mobility limitations.
108 Pre-post change in mental health and brain structure in pediatric mild traumatic brain injury
Fanny Degeilha, Tilmann von Soestb, Claire Curya, Lia Ferschmannb, Christian Tamnesb,c,d
aUniversity of Rennes, CNRS, Inria, Inserm, IRISA UMR 6074, EMPENN – ERL U 1228, Rennes, France, bPROMENTA Research Center, Department of Psychology, University of Oslo, Oslo, Norway, cNORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway, dDepartment of Psychiatric Research, Diakonhjemmet Hospital, Oslo, Norway
ABSTRACT
Introduction: Studies comparing children with and without a traumatic brain injury (TBI) have shown that pediatric TBI is associated with difficulties in a large range of functional domains, including emotion and behavior (Catroppa et al., 2015), as well as with changes in brain morphometry (King et al., 2019). However, whether these differences already existed before the injury and constitute a risk-factor, or emerge as a consequence of the injury remains an unsolved question. The large population-based Adolescent Brain Cognitive Development (ABCD) Study (Casey et al., 2018) provides a rare opportunity to explore this question.
Objective: This pre-post design study aimed to examine longitudinal changes in mental health, and brain morphometry following pediatric mild TBI (mTBI).
Methods: The following baseline and 2-year follow-up data from the ABCD 4.0 curated data release were used: 1) The Parent Ohio State TBI Screen-Short Modified Report (Bogner et al., 2017) to retrospectively identify children with no-TBI (n = 6,780; baseline mean age = 9.91 years; 3,309 [49%] males) and children who sustained a mTBI (i.e., head or neck injury with loss of consciousness ≤ 30 min or memory loss) between baseline and a 2-year follow-up (n = 145; baseline mean age = 9.97 years; 86 [59%] males), 2) internalizing and externalizing problem t-scores (syndrome scales) and DSM-5-oriented scales from the Child Behavior Checklist (CBCL, Achenbach & Rescorla, 2000), and 3) right and left hemisphere total cortical volume and mean cortical thickness computed on T1-weighted images by the ABCD group. Scanner effects were controlled for using longitudinal-ComBat (Beer et al., 2020). Multigroup latent change score models were constructed with the lavaan 0.6–12 package (Rosseel, 2012) in R (version 4.1.2) to estimate individual change between baseline and follow-up for mental health (CBCL scores), cortical volume and cortical thickness. Group differences in 4 parameters of interest (mean of the baseline score, rate of change over time, and variances of the baseline and of the change) were tested using chi-square difference tests (Kievit et al., 2018). Sex and parental education were included as covariates.
Results: As compared to non-injured peers, children with mTBI show no different trajectories in internalizing and externalizing problems, but different trajectories in ADHD and anxiety disorder scores. While similar at baseline (pre-injury), ADHD and anxiety disorder scores increased in children with mTBI and decrease in their non-injured peers. Children with mTBI showed greater cortical volume and thickness at baseline compared to non-injured peers, but no differences in change.
Conclusion: This pre-post study suggests an increased risk of anxiety disorder and ADHD as a consequence of a mTBI, rather than a preexisting risk factors. Further explorations using additional brain metrics and timepoints (ABCD release 5.0 – fall 2022) will be conducted to fully understand these findings.
110 Coping with menopause after traumatic brain injury
Robin Hanksa
aWayne State University School Of Medicine, Department of Physical Medicine and Rehabilitation, Detroit, USA
ABSTRACT
Menopause is a biological process that all women experience, yet little is known about the menopause transition after TBI. The experience of menopause may differ for women who sustain a TBI, because some of the symptoms associated with the hormonal disruption may have an interactive effect with common sequelae of TBI (e.g., depression, irritability, sleep dysfunction, fatigue). Based on the results, therapeutic interventions or coping strategies could be developed to help deal with these experiences. Participants were 221 women 40–60 years old who were not taking hormones and had intact ovaries. Women with TBI had mild-complicated to severe injuries, were at least 2 years post injury, had a menstrual period after injury, and were living in the community. Eighteen menopause symptoms were collected for frequency and severity weekly and monthly. We also assessed sleep, anxiety, depression, and fatigue. Results indicated that symptoms associated with changes in estrogen were similar between women with and without TBI. Among premenopausal women, TBI and non-TBI groups did not differ significantly in symptoms associated with declines in estrogen (e.g., hot flashes, night sweats, bowel and bladder sequelae, breast tenderness). However, premenopausal women with TBI reported body aches and headaches, as well as difficulties with memory, focus, fatigue, cognitive concerns, sleep, and anxiety significantly more than women who were premenopausal without TBI. Among postmenopausal women, those with TBI reported significantly more hot flashes, crying spells, poor memory, worry, moodiness, panic attacks, cognitive concerns, sleep disturbance, and anxiety than women without TBI. Postmenopausal and premenopausal women with TBI differed only for hot flashes and breast tenderness. In contrast, women without TBI who were postmenopausal noted significantly worse hot flashes, night sweats, restlessness, poor memory, irritability, sleep disturbance, and anxiety than their premenopausal counterparts without TBI. Postmenopausal women without TBI also reported more types of symptoms and experienced those symptoms more frequently than premenopausal women with TBI. Overall, the pattern indicated that women with TBI experienced menopause as less of a “change of life” than did women without TBI. One possible reason for this difference is that women with TBI have already been exposed to changes cognitively, physically, and emotionally. Many of the symptoms associated with menopause overlap with symptoms commonly experienced after TBI at any stage of life. They have developed resilience for managing these types of difficulties and therefore experience them as less distressing than their peers without TBI, for whom these challenges are new and therefore relatively burdensome. The good news is that established coping strategies that have been developed to deal with the challenges of adjusting to TBI appear to be beneficial to dealing with additional experiences that may occur with menopause.
111 Efficacy of a 12-month weight-loss program (Glb-Tbi) delivered to adults with traumatic brain injury: results from a randomized controlled trial
Simon Drivera,e, Evan McShana,e, Dr. Chad Swanka,e, Stephanie Calhouna,e, Monica Bennetta, Librada Callendera,e, Alexandria Holdena,e, Dr. Shannon Juengstb, Kathleen Bellc, Megan Douglasa,e, Dr. Kaye Kramerd, Randi Dubiele
aBaylor Scott & White Research Institute, Dallas, USA, bTIRR Memorial Hermann, Houston, USA, cUniversity of Texas Southwestern, Dallas, USA, dUniversity of Pittsburgh, Pittsburgh, USA, eBaylor Scott & White Institute for Rehabilitation, Dallas, USA
ABSTRACT
Obesity after traumatic brain injury (TBI) is a public health issue and no evidence-based weight loss interventions exist to meet the unique needs of individuals after TBI. The purpose of this study is to (a) examine the efficacy of the Diabetes Prevention Program Group Lifestyle Balance for TBI (GLB-TBI) weight-loss intervention compared to an attention control for primary (weight-loss) and secondary health outcomes; (b) determine participant compliance with the GLB-TBI; and (c) determine if compliance is associated with improved outcomes. Individuals with moderate to severe TBI, age 18 to 64 years, ≥ six months post injury, and body mass index of ≥ 25 kg/m2 were randomized to a 12-month, 22-session GLB-TBI intervention or attention control condition. Weight-loss (lbs.), anthropometric, biomarkers, and patient reported outcomes were collected at baseline, 3, 6, and 12-months. The GLB-TBI group (n = 27) lost 17.8 ± 41.4lbs (7.9%) over the 12-month program and the attention control group (n = 27) lost 0 ± 55.4lbs (0%). The GLB-TBI group had significant improvements in diastolic blood pressure, triglycerides, and HDL cholesterol. GLB-TBI attendance was 89.6% and weekly self-monitoring of diet and activity was 68.8%. Relative to baseline, the GLB-TBI compliant group (≥80% attendance; ≥85% self-monitoring; n = 10) had a statistically significant decrease in weight at each assessment, the non-compliant group had a significant decrease between 6 and 12 months (n = 17), with no change in weight in the attention control group (n = 27). Findings suggest for adults with TBI who are overweight or obese, participation in the GLB-TBI can significantly reduce weight and metabolic risk factors and increase self-reported habits for diet and exercise.
112 Efficacy of a 12-month weight-loss intervention (Glb-Cva) delivered to adults with stroke: results from a randomized controlled trial
Simon Drivera,b, Evan McShana,b, Chad Swanka,b, Stephanie Calhouna,b, Megan Douglasa,b, Alexandria Holdena,b, Monica Bennetta,b, Librada Callendera,b, Christa Ochoaa,b, Sridevi Mukkamalab, Simon Driver, Kaye Kramerv
aBaylor Scott & White Research Institute, Dallas, USA, bBaylor Scott & White Institute for Rehabilitation, Dallas, USA, cUniversity of Pittsburgh, Pittsburgh, USA
ABSTRACT
Stroke increases an individual’s risk for diabetes and metabolic syndrome, yet few interventions exist that have been tailored to the population’s unique needs. The aims of this study were to take the evidence-based Diabetes Prevention Program Group Lifestyle Balance program (DPP-GLB), modified for people post stroke (GLB-CVA), and examine feasibility and efficacy of the program (6-month randomized controlled trial [RCT] data and 12-month combined group data). Adults (18–85 years of age), >12 months post stroke, and body mass index (BMI) ≥25 kg/m2 were included in this study. Using cluster randomization, 65 people were assigned to either the GLB-CVA intervention or a 6-month wait-list control (WLC). Participants completed the 12-month, 22 session GLB-CVA intervention, with attendance and assessment of weight, anthropometric, biomarker, functional, and patient reported outcome data collected at baseline, 3, 6, and 12 months. Results of the intervention showed high attendance (90%) and dietary and activity tracking (71%) suggesting that the program is feasible to deliver. 6-month RCT data indicate significant weight-loss (p = 0.005) in the GLB-CVA group (7.4 ± 13.6 lbs., 3.65%) compared to the WLC (0.1 ± 10.1 lbs., 0%), and significant changes in arm circumference (p = 0.04), HDL cholesterol (p = 0.028), 8-year diabetes risk (p = 0.011), and pain interference (p < 0.001). Combined 12-month data showed participants lost 10.1 ± 16.8 lbs. (4.88%) with significant differences in waist circumference (p = 0.001), diastolic blood pressure (p < 0.001), pain (p = 0.001), social participation (p = 0.025), and eating practices (p = 0.01) and habits (p < 0.001). Data indicate that for individuals who are overweight or obese following stroke, engagement in the GLB-CVA can result in weight loss and improved health. Future efforts should examine the effectiveness of participation in real-world settings and focus on knowledge translation efforts including training materials on delivery of the modified curriculum.
113 Linking metabolic biomarkers with healthy lifestyle outcomes after stroke
Chad Swanka,b, Chad Swanka,b, Teodoro Bottiglieria, Sandy Zurawskia, Evan McShana, Librada Callendera,b, Monica Bennetta, Randi Dubielb, Simon Drivera,b
aBaylor Scott & White Research Institute, Dallas, USA, bBaylor Scott & White Institute for Rehabilitation, Dallas, USA
ABSTRACT
Participation in a healthy lifestyle intervention such as the Diabetes Prevention Program Group Lifestyle Balance – adapted for stroke (GLB-CVA) may reduce stroke burden. Identifying biomarkers associated with lifestyle changes may enhance an individualized approach to stroke recovery. The purpose of this study was to investigate metabolic biomarkers related to cardiovascular and neurological function in individuals with stroke participating in the GLB-CVA study and healthy participants. Participants with chronic (>12 months) stroke were recruited to this single phase, assessor-blinded, wait-list randomized controlled trial if they were overweight (BMI ≥25 kg/m2) and had physician approval to be physically active and make dietary changes. Participants randomized to the GLB-CVA program completed 22 educational sessions addressing behavioral principals of dietary and physical activity. Biomarkers included Plasma irisin, vascular endothelial growth factor (VEGF), lipoprotein-associated phospholipase A2 (Lp-PLA2), insulin-like growth factor 1 (IGF-1) and brain-derived neurotrophic factor (BDNF) and were collected at baseline, 3, and 6 months. Age matched healthy individuals were recruited for biomarker assessment. Forty-eight individuals with chronic stroke (GLB-CVA = 24; control = 24) and 19 healthy individuals completed this study. Compared to healthy adults, participants with stroke at baseline had significantly higher tHcy levels (p < 0.001) and significantly lower PLA2 levels (p = 0.016). No significant interactions were observed for any of the biomarkers between the GLB-CVA and control group at any time point. Participants with >5% of their body weight by 6 months experienced a significant interaction between weight loss and time (p = 0.038) for PLA2. Participation in a healthy lifestyle program for six months did not result in changes to select metabolic biomarker levels for our participants with chronic stroke compared to those with stroke who did not participate. For those individuals with stroke who achieved the 5% weight loss goal of the healthy lifestyle program, we observed a steady state in PLA2 over time compared to those who did not experience weight loss.
114 Efficacy of a group-based education intervention for people with traumatic brain injury: results from a 12-month randomized controlled trial
Evan McShana,b, Megan Douglasa,b, Shannon Juengstc, Donna Noorbakhshb, Stephanie Calhouna,b, Monica Bennetta, Alexandria Holdena,b, Simon Driver, Randi Dubielb
aBaylor Scott & White Research Institute, Dallas, USA, bBaylor Scott & White Institute for Rehabilitation, Dallas, USA, cTIRR Memorial Hermann, Houston, USA
ABSTRACT
There are potential adverse effects of being randomized to a no-treatment or wait-list control group. Attention control is considered highly valid in behavioral research, as it removes potential threats to internal validity commonly found in waitlist control study designs (e.g., participants on waitlist finding alternative treatments). We developed an attention control condition for a weight loss RCT (GLB-TBI, NCT03594734) called the Brain Health Group (BHG). The BHG built upon an existing group-based community-based educational support group delivered at our hospital and focused on self-management, TBI education, and goal setting. The objectives of this study are to (1) describe compliance (attendance; goal tracking) with the 12-month Brain Health Group (BHG) self-management intervention; (2) examine efficacy of the BHG for improving self-efficacy (primary) and secondary outcomes compared to a time and attention-matched weight-loss intervention; and (3) describe findings from the program evaluation of the BHG including quantitative (i.e., perceived helpfulness, barriers, supports) and qualitative data (i.e., brief interview with directed questions).Participants included 29 English-speaking, community-dwelling adults (18–64 years old), who had a moderate to severe TBI, and ≥six months post injury. Outcome data were collected at baseline and 12 months and included self-efficacy (primary), depression, satisfaction with life (SWL), self-rated abilities for health practices (SRAHP), and alcohol use. Additionally, program evaluation was conducted using an Exit Survey at 12 months. Results showed BHG attendance was 89% and average goal tracking was 59%. Within group analysis of the BHG did not show a significant change in self-efficacy, depression, SWL, or alcohol use over the 12-month program. However, a significant increase in the SRAHP score (mean change = 9.0 (±16.5); Cohen’s d effect size = 0.55; p = 0.018) was reported. The SRAHP domains with an increase were nutrition (mean = 2.5 (± 4.9); d = 0.51; p = 0.029), exercise (mean = 2.5 (± 5.8); d = 0.43; p = 0.045), and health practices (mean = 2.3 (± 4.6); d = 0.50; p = 0.024). Participants also perceived the BHG program as helpful during the exit interview. Our results suggest that people with TBI can successfully engage in the BHG self-management program and generally perceived the program as helpful in enhancing knowledge about brain health and awareness of how to enhance self-management skills.
115 Two brains are better than one: partnering with peer mentors in a weight loss program for people with brain injury
Evan McShana,b, Dr. Simon Drivera,b, Stephanie Calhouna,b
aBaylor Scott & White Research Institute, Dallas, USA, bBaylor Scott & White Institute for Rehabilitation, Dallas, USA
ABSTRACT
Individuals with neurologic conditions such as traumatic brain injury (TBI) and stroke are at an increased risk for obesity and obesity-related comorbid conditions (e.g., heart disease, diabetes, recurrent stroke) than those without and TBI or stroke. Our team used a community based participatory approach to modify the Diabetes Prevention Program Group Lifestyle Balance (DPP-GLB) program to meet the unique weight loss needs of people with TBI (GLB-TBI) and stroke (GLB-CVA). We then delivered both programs to 122 individuals with brain injury. The purpose of this paper is to (1) describe the process of incorporating peer mentors, individuals with brain injury who have experience with the DPP-GLB into program delivery and (2) present results from Exit Survey data. Twenty-five peer mentors between 25 and 70 years of age were included across both programs. Peer mentors attended up to six sessions each (out of 22 total) and provided insight and strategies for overcoming barriers that individuals may encounter while trying to maintain a healthy lifestyle. Peer mentors also provided optional support via text, e-mail, or Facebook outside of the program. Results from Exit Surveys administered to participants at the end of both programs showed the overall mean helpfulness of the peer mentors was 4.37 out of 5. Participants in the GLB-TBI program found the peer mentors to be most helpful by helping them feel more motivated or inspired to lead a healthy lifestyle (4.56 out of 5) and participants in the GLB-CVA program found them most helpful by providing support for making lifestyle changes (4.3 out of 5). Qualitative data supported Likert Scale data and participants felt connected to peer mentors and would recommend them for future programs. Feedback from participants and peer mentors suggest that incorporating peer mentors into the delivery of two weight loss programs for people with brain injury is feasible and helpful for participants. Our team learned valuable lessons during both programs and have identified areas for future growth and opportunity.
116 School-to-prison pipelines for children with brain injury
Hope Kenta, Amanda Kirbyb, Lee Hogartha, George Leckiec, Rosie Cornishc, Huw Williamsa
aUniversity of Exeter, Exeter, United Kingdom, bUniversity of South Wales, Wales, United Kingdom, cUniversity of Bristol, Bristol, USA
ABSTRACT
Introduction: Both school exclusion and brain injury are prospective risk factors for subsequent contact with criminal justice system. However, it has not yet been established whether school exclusion and neurodisability are associated with criminalization at a younger age. It is also unclear how school exclusion and neurodisability interact to promote earlier criminalization. Contact with the criminal justice system at a young age is an important outcome as it compounds existing social problems, and severs existing peer and family support networks. Justice system contact is also criminogenic – children who are first arrested younger are more vulnerable to later re-offending.
Method: We addressed this gap with a sample of 3,035 convicted adult male prisoners, who completed the Do-IT Profiler screening tool in HMP Parc (Wales, UK). They were screened for neurodisability associated with brain injury as part of usual routine in the first 6 weeks in prison. The Do-IT profiler is a computerized screening tool, organized into modules. It has built in accessibility functions, such as the option to have questions and answers read aloud, and the ability to change the text and background color. A staff member was present to assist with completion.
Results: Multiple school exclusions increased risk for early conviction, with those excluded once, 2–3 times, and 4 or more times being first convicted 3, 5, and 6 years earlier than the never-excluded cohort respectively. Of the excluded cohort, 45% were sent to a PRU (29% of the total sample). They were first convicted an average of 2 years younger than those who were excluded but never sent to a PRU, and an average of 6 years younger than those who were never excluded. Higher levels of functional neurodisability were associated with being younger at first conviction, and school exclusion partially mediated the relationship between neurodisability and younger first convictions.
Implications: There are several ways we can improve educational support for children with neurodisability resulting from brain injury going forwards, and early intervention is key to breaking the ‘school-to-prison pipeline.’ Providing SEN assessments for children who have been to hospital for a head injury, screening for brain injuries at the point of first exclusion, and providing more resource for tailored support plans to retain children in mainstream schools is key to preventing children ending up in the justice system. Retaining children in mainstream school could be a key intervention strategy to improve life outcomes for vulnerable children. This involves improving screening for neurodisabilities, and provision for children with neurodisabilities within schools. If future longitudinal research corroborates our findings, policies relating to school discipline should prioritize discouraging exclusion as a punishment.
119 B cell treatment induces a neuroprotective microenvironment after traumatic brain injury
Liam Dwyera, Saumya Maheshwaria, Mark Poznanskya, Michael Whalen, Ruxandra Sirbulescua,c
aVaccine and Immunotherapy Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA, bNeuroscience Center, Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, USA, cDepartment of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
ABSTRACT
Traumatic brain injury (TBI) remains a major cause of death and disability worldwide, with approximately 1% of the population affected by such an injury every year. At a cellular level, many neurodegenerative effects associated with TBI can be traced to inflammatory responses after the initial insult, when peripheral immune cells infiltrate the brain in large numbers. Despite significant medical need, there are currently no immunomodulatory therapeutic agents available for the treatment of patients with TBI. Our previous work has demonstrated that exogenous mature naïve B220+/CD19+/IgM+/IgD+ B cells are potent modulators of inflammatory responses, and that B cell treatment was associated with structural and functional neuroprotection after TBI. Here, we used a mouse model of unilateral controlled cortical contusion TBI to assess post-injury cellular immune mechanisms associated with neuroprotection after acute intraparenchymal delivery of B lymphocytes. At post-injury intervals ranging from 18 hours to 2 months, the immune infiltration and cytokine production in the ipsilateral and contralateral brain hemispheres of B cell-treated and control animals was assessed using multiplexed flow cytometry. Early cellular infiltration at the site of injury predominantly comprised myeloid cells, particularly neutrophils (~45%) and monocytes/macrophages (~35%). While neutrophil numbers declined to negligible levels by 2 months post-TBI, monocytes/macrophages persisted in situ, albeit with an approximately 10-fold reduction in overall numbers. Notably, in the presence of exogenous B cells at the injury site there was a significant increase in the proportion of M2-like monocytes/macrophages as early as 2 days and up to 2 months after injury and treatment. In parallel, the relative proportion of CD45-high (activated) microglia was significantly reduced starting at 4 days and up to 2 months post injury. B cells placed in the injured brain showed a complex time-dependent response to the injury microenvironment, absent in sham-lesioned brain tissue. After 48 hours in situ, the exogenous B cells upregulated the production of multiple immunomodulatory cytokines, including IL-10, IL-35, and TGF-beta, but also IL-2, IL-6, and TNF-alpha. In the presence of B cells, infiltrating CD45-high immune cells at the lesion site significantly increased their production of anti-inflammatory cytokines IL-10, TGF-beta, and IL-35 and reduced production of TNF-alpha and IL-2 as compared to saline-treated controls. This downstream effect was most pronounced 4 days after injury/ treatment and persisted up to 2 months in the residual infiltrating immune cells. Confocal imaging of the injury sites confirmed that infiltrating CD11b-positive monocytes/macrophages come into early direct contact with the exogenous B cells, suggesting that regulatory interactions may occur via cell-cell contact as well as through paracrine cytokine signaling. We hypothesize that peripheral myeloid cells, particularly infiltrating monocyte/macrophages, are key mediators of the neuroprotective immunomodulatory effects observed after B cell treatment.
120 Barriers and facilitators to a progressive walking intervention for adults with persistent symptoms of a mild traumatic brain injury
Bonnie Swainea, Christophe Alariea, Michelle McKerralb, Elaine De Guiseb, Marietta Kersaléa, Béatrice Van Het Hooga, Isabelle Gagnonc
aSchool of Rehabilitation, Université de Montréal – CRIR, Montreal, Canada, bDepartment of Psychology, Université de Montréal-CRIR – CRIR, Montreal, Canada, cSchool of Physical and Occupational Therapy, McGill University – Montreal Childrens Hospital, Montreal, Canada
ABSTRACT
Introduction: Physical activity (PA), including walking, is recommended to manage persisting symptoms following mild traumatic brain injury (mTBI) and to facilitate the return to usual activities. Little is known about the factors (barriers and facilitators) influencing participation in walking interventions, accessible and low intensity physical activities for adults with persisting symptoms of a mTBI.
Objective: This study explored the factors reported to influence the participation of adults with persisting symptoms of a mTBI in an 8-week telehealth progressive walking intervention.
Method: This study followed a qualitative descriptive design. An 8-week personalized progressive walking intervention was delivered remotely to adults with persisting symptoms of a mTBI (> 3 months). Participants attended weekly virtual sessions with one of four trained research assistants (RA) who documented, in each participant’s logbook, barriers and facilitators to walking experienced during the previous week and those anticipated the following week. During a recorded semi-structured exit interview with an RA (end of week 8), participants were asked to identify their most significant barriers and facilitators experienced during the entire intervention. Interviews were transcribed verbatim and semi-deductive qualitative content analyses were performed using data from the interviews’ transcripts and participants’ logbooks. The International Classification of Functioning, Disability, and Health (ICF) structured the iterative content analysis to enable classifying the barriers and facilitators into ICF domains.
Results: Twenty adults (16 women, mean age 42.5 ± 11.5 years) with persisting symptoms of a mTBI (mean duration 9.25 ± 6.4 months) participated in the walking intervention. Sixteen factors were identified: 5 relating to body functions (motivation, musculoskeletal pain, post-concussion symptoms, sleep, higher-level cognitive functions) and 6 factors relating to activity and participation (handling stress, carrying out daily routine, domestic life, work and education, recreation and leisure, and relationships with friends). Four factors relating to the environment (products and technology, natural environment, climate, and motorized transport) and one personal factor (perception of general health status) were also found. Most factors mutually influenced each other. Barriers to walking were similar to those found for physical activity in general (e.g. climate) but some could be specific to mTBI. For example, higher-level cognitive function (e.g., planning) seems to influence how a person post mTBI can or cannot maintain their walking goals, suggesting that clinicians may have to support PA planning/scheduling.
Conclusions: Without knowing what can influence the ability/desire to participate in a walking intervention post mTBI can make it challenging to identify key factors upon which to act. Results provide additional walking program considerations for clinicians and adults with an mTBI to improve service delivery related to walking programs, adherence to walking goals and potentially health-related outcomes post-mTBI.
121 Accessibility in the age of Alexa: supporting cognition, communication, and physical access for those with acquired brain injuries
Marie Coxa, Sharon Leahya
aNational Rehabilitation Hospital, Dublin, Ireland
ABSTRACT
Smart home technology enables access to devices through various alternative control methods e.g. voice control or touch. Examples of smart home technology include Amazon Alexa, Google Home etc. These systems give individuals access to control TV, lights, music, and internet. Given the mainstream nature and ready availability of these technologies we have a responsibility as clinicians to incorporate these into our practice and provide information and trial opportunities for our clients with an acquired brain injury (ABI). Our presentation aims to outline the impact of these technologies with clinical case examples and feedback from those living with acquired brain injuries. The case studies will demonstrate the impact of these technologies on those with cognitive, communication and physical impairments arising from an ABI. For those with cognitive difficulties smart home technology can be used to support their engagement with valued leisure activities e.g., play music from YouTube or tell you the news. This technology can also be used to support cognitive functioning e.g. to set reminders or timers which are an excellent external memory strategy. For those with communication disorders high tech AAC systems can interact with digital assistants to enable access to the person’s environment. Digital Assistants can also be used therapeutically for those with speech and language disorders e.g. dysarthria, aphasia. Using the digital assistant acts as an external motivator and biofeedback tool which promotes the use of compensatory strategies for increased speech intelligibility. For those with physical difficulties smart home technologies allow control over the environment such as turning on and off lights, controlling the television and opening and closing blinds. This can reduce carer burden and the need for physical assistance from others and increase a person’s sense of autonomy and control. Smart home technologies provide a cost-effective method of accessing and controlling the environment via mainstream means without the connotation of disability. Having access to the devices within a supported living environment provides the opportunity for individuals to trial these technologies in a meaningful and contextual environment. Like all technologies, smart home technologies are not without limitations. In order to use these devices a good quality Wi-Fi system is required. In order to select and set-up these devices individuals require a good level of technological knowledge and skill. There may also be data protection, privacy, and security concerns in relation to the use of these devices. Despite these limitations the opportunity to trial such technologies is an essential component of a person with an ABI’s rehabilitation journey. Such trials can support informed choices and decision making and eliminate abandonment of technology. Further benefits of smart home technologies include the positive psychological impact of increasing client autonomy, independence, and control.
122 Technology-based interventions to self-manage challenging behaviors in people with acquired brain injury: a scoping review
Charlotte Hendryckxa,b,c, Emily Nalderd, Emma Draked, Éliane Leclairec, Evelina Pitucha,e, Charles Gouin-Vallerandf,g,h, Hugo Girardh, Rosalie H. Wangd,i, Valérie Poulinj,k, Carolina Bottaria,e
aCentre for Interdisciplinary Research in Rehabilitation of Greater Montréal, Institut universitaire sur la réadaptation en déficience physique de Montreal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montréal, Canada, bCenter for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Center de Recherche du CIUSSS NIM, Montréal, Canada, cDepartment of Psychology, Université de Montréal, Montréal, Canada, dDepartment of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, eSchool of Rehabilitation, Université de Montréal, Montréal, Canada, fCentre de Recherche Createch sur les Organizations Intelligentes, Université de Sherbrooke, Sherbrooke, Canada, gDOMUS Laboratory, Université de Sherbrooke, Sherbrooke, Canada, hUniversité de Sherbrooke, Sherbrooke, Canada, iIntelligent Assistive Technology and Systems Lab, KITE-Toronto Rehabilitation Institute, Toronto, Canada, jDepartment of Occupational Therapy, Université du Québec à Trois-Rivières, Trois-Rivières, Canada, kCenter for Interdisciplinary Research in Rehabilitation and Social Integration, Québec, Canada
ABSTRACT
Introduction: Challenging behaviors, such as aggression, inappropriate social behaviors or lack of initiation, are one of the most serious sequelae after an acquired brain injury (ABI). Because of their chronicity, challenging behaviors are a significant predictor of community reintegration for people with ABI. Interventions based on new technologies have been identified as a research priority to improve community reintegration in ABI.
Objective: To identify the nature and extent of literature exploring technology-based interventions used to enable real-time self-management of challenging behaviors in people with ABI.
Methods: A scoping review of peer-reviewed literature was conducted using the methodological framework of Arksey and O’Malley (2005) and the Preferred Reporting Items for Systematic reviews and Meta-Analyses checklist items Extension for Scoping Reviews checklist (Tricco et al., 2018). This scoping review was conducted using five databases (MEDLINE, Embase, PsycInfo, CINAHL, Web of Science) retrieving literature published between 2000 and 2021. The search strategy was formulated with an academic health science research librarian, using search terms based on the 3 main concepts of this study: “acquired brain injury,” “smart technologies,” and “challenging behaviours.” The following inclusion criteria were used: (1) primary studies (all study designs), (2) humans with a primary diagnosis of ABI and/or with secondary comorbidities, aged 18–64 years and identified as having challenging behaviors, (3) real-time technology intervention, and (4) published articles, conference proceedings, and abstracts. Two independent reviewers screened articles and reviewed those that were included. The Overt Behavior Scale (Kelly et al., 2006) was used to categorize challenging behaviors, while the FASTER framework (Wang et al., 2021) was used to categorize the phase of development for each technological intervention.
Results: From an initial 2437 articles, 21 were reviewed and 11 were included. All articles were published after 2010, including eight published after 2013. Seven articles were case studies and randomized controlled trials, and ten articles were conducted in American or European settings. When reported, four studies focused on mild traumatic brain injury (TBI) and four studies on moderate-severe TBI. Technologies mainly targeted emotional lability, inappropriate social behaviors, and behavioral manifestations of cognitive impairments. Nine studies used biofeedback technology and smartphone applications to facilitate self-management of challenging behaviors. Nine technologies were in phase 3 of the FASTER framework (scaled evaluation and implementation).
Conclusion: The range of technologies employed and behaviors targeted show the promise of using technology as an intervention that could play an important role in the management of challenging behaviors, though this field of study is still recent and in its early stages of exploration. Future research is needed to identify the effectiveness of these technologies in reducing and managing behaviors and document the acceptability of these technologies for use by people with ABI and their families in daily life.
123 Nationwide emergency department sample 2018 mild traumatic brain injury visits – associations of elderly, sex, and fall mechanism of injury
Carrie Barretta, Kieran Fogartya
aWestern Michigan University, Kalamazoo, USA
ABSTRACT
Purpose: Mild traumatic brain injury (mTBI) was 72.7% of all severities of traumatic brain injury seen in U.S. emergency departments (ED) in 2017. Although defined as “mild,” research reports increases in numbers of mTBI ED visits and negative quality of life impact. Gaps were found in additional medical care after mTBI ED discharge. Only 52% of those with persistent mTBI symptoms followed up with medical providers after discharge. Older adults are more susceptible to experiencing mTBI compared to younger ages, however limited information exists regarding associations of older ages and subsequent ED visits due to ongoing mTBI symptoms. Sex (male, female) and associations with returning mTBI ED visits remain unclear in current literature. Research supporting associations between fall injury and mTBI is lacking. This study aims to investigate mTBI initial ED visit (mTBIi) and mTBI subsequent ED visit/s (mTBIs) through associations with age, sex, and fall injury. The null hypotheses are: 1) the mean age of mTBIs will not be older compared to all other ages; 2) male/female and mTBIs will not have associations; and 3) fall injury and mTBIs will not have an association.
Methods: The study was a cross-sectional design using secondary population data from the 2018 Nationwide Emergency Department Sample (NEDS) dataset. The total sample size was 261,349. The independent variables were mTBIi and mTBIs. An independent t-test was used to calculate age mean differences between mTBIi and mTBIs. Pearson’s Chi-squared analyses were used to determine associations of age, sex, and fall injury with mTBIi and mTBIs.
Results: Visits with mTBIi and mTBIs totaled 256,417 and 4,932 respectively. The total mTBI aged > 65 was 63,465. The mean age of mTBIs was 50.41 which was older than mTBIi mean age of 41.38 (CI 95% p < 0.05, p = 0.025). Visits of ages > 65 were associated with mTBIs (p < 0.001). More males than females were associated with mTBIs in all ages (p = 0.022). Fall injury is not found to be associated with mTBIs in all ages (p = 0.000).
Conclusion: The first null hypothesis was rejected as the mean age of mTBIs was older than mTBIi. Those aged > 65 had more mTBIs than mTBIi, indicating possible poorer recovery from mTBIi in elderly populations. The second null hypothesis was rejected as mTBIs of all ages were more male than female. The third null hypothesis was accepted as fall injury of all ages was not associated with mTBIs. Future studies will select out ages > 65 for male/female and investigate mTBIs and fall injury associations.
Clinical Relevance: Interdisciplinary collaboration to create follow-up models post mTBI ED visits may be needed in those > 65.
125 Developing an evidence-based framework for early, interdisciplinary vocational rehabilitation for adults with brain injury
Kerrin Wattera,c, Alena Murraya, Vanette McLennanb,c, Jessica Voglera, Sarah Jefferya, Mandy Nielsena,c, Shelley Ehlersa, Areti Kennedyac
aABI TRS, Metro South Health, Queensland Health, Woolloongabba, Brisbane, Australia, bGriffith University, School of Allied Health Sciences, Gold Coast, Australia, cThe Hopkins Center – Metro South Health & Griffith University, Brisbane, Australia
ABSTRACT
Adults with acquired and traumatic brain injury often struggle to access specialized vocational rehabilitation to support their goals of returning to work. Identified barriers include limitations in service delivery, timing of services and access to knowledgeable and skilled staff. Solutions to improve access and availability of vocational rehabilitation include services delivering vocational rehabilitation as a component of a rehabilitation program. Further, using a clinical framework for service delivery should improve the consistency, quality and overall provision of vocational rehabilitation; positively impacting client experiences and outcomes. This study aimed to develop an evidence-based framework for the delivery of vocational rehabilitation during early community rehabilitation for adults with acquired and traumatic brain injury. This occurred within a specific service context, i.e., a state-wide transitional community rehabilitation service for adults with brain injury, in Queensland, Australia.
Methods: The evidence-based framework for vocational rehabilitation was developed using an emergent multi-phase design. Four study phases were undertaken to identify and generate the contextual knowledge and evidence-base, guided by evidence-based practice models. These findings informed development of the vocational rehabilitation framework (phase five). The framework was also informed by the implementing service’s model of care, national rehabilitation standards, guidelines for complex intervention development, guidelines for model of care and framework development, and the knowledge to action framework.
Results: An evidence-based framework was developed, providing a structure for delivering vocational rehabilitation as a component of interdisciplinary community rehabilitation. It uses a hybrid model of vocational rehabilitation, involving aspects of case-coordination and program-based vocational rehabilitation, delivered across 5 phases of clinical activity (assessment, goal setting and rehabilitation planning, intervention, monitoring and evaluation, discharge). The framework details the specific roles and activities to be undertaken by a case coordinator and the treating team, and also includes key service delivery features (access and timing, a coordinated interdisciplinary approach, supporting families).
Conclusions: The developed framework has been implemented in clinical practice, increasing the delivery and consistency of vocational rehabilitation service provision as a component of community rehabilitation. Translation and implementation to other services/contexts is possible, which should improve access to vocational rehabilitation for adults with brain injury.
126 Serum Zinc and long-term prognosis after acute traumatic brain injury with intracranial injury: a multicenter prospective study
Eujene Junga, Young Sun Roa, Sang Do Shina
aChonnam National University Hospital, Gwangju, South Korea
ABSTRACT
Serum zinc levels in the acute stages after traumatic brain injury (TBI) may be capable of predicting clinical and functional prognoses. This study aimed to evaluate the association between serum zinc levels and long-term survival and neurological outcomes in TBI patients with intracranial injury.
This multicenter prospective cohort study enrolled adult TBI patients with intracranial injury, who visited emergency departments between December 2018 and June 2020. Serum zinc levels drawn within 24 hours after injury were categorized into 4 groups: low (<80.0 mcg/dl), low-normal (80.0–100.0 mcg/dl), high-normal (100.1–120.0 mcg/dl), and high (>120.0 mcg/dl). The study outcomes were 6-month mortality and disability (Glasgow Outcome Scale, 1–3). A multilevel multivariable logistic regression analysis was conducted to estimate associations between serum zinc and study outcomes.
From the eligible TBI patients (N = 487), the median (interquartile range) serum zinc level was 112.0 mcg/dl (95.0–142.0). Six-month mortality and disability were 21.1% (103/487) and 29.6% (144/487), respectively. Compared to the high-normal zinc group, there were significant associations to 6-month mortality and disability observed in the low zinc group (aORs (95% CIs): 1.91 (1.60–2.28) and 1.95 (1.62–2.36) for the low group; 1.14 (0.67–1.94) and 1.15 (0.91–1.46) for the low-normal group; and 0.72 (0.44–1.16) and 0.88 (0.61–1.27) for the high group, respectively).
Among the 122 TBI patients with diabetes mellitus, the low zinc group showed higher incidence of 6-month mortality (aOR (95% CI): 9.13 (4.01–20.81)) compared to the high-normal zinc group. Moreover, the low and low-normal groups had higher odds for 6-month disability (aORs (95% CIs): 6.63 (3.61–12.15) for the low group and 2.37 (1.38–4.07) for the low-normal group).
Serum zinc deficiency is associated with higher incidence of 6-month mortality and disability after injury for TBI patients with intracranial injury.
127 The “family first” project – outcomes from a community-based intervention programme for families of children with acquired brain injury
Chris McCuskera, Catherine Quinnb, Bridget Smythb, Meg Irwinb, Eunan McCruddenc
aSchool of Applied Psychology, University College Cork, Cork, Ireland, bBrain Injury Matters, Belfast, United Kingdom, cBelfast Health and Social Care Trust, Belfast, United Kingdom
ABSTRACT
Background: Family focused interventions have shown increasing promise and relevance for improving outcomes in children with acquired brain injury (ABI). Ecological models also attest to the importance of health and education systems supporting the family to support the child. We formulated, delivered and evaluated a new community-based intervention programme to bolster family resilience and coping skills and the capacity of health and education systems to support the child and family.
Methods: An intervention heuristic, incorporating psychoeducation, problem solving therapy and tailored coping coaching provided the framework for a home-visiting project with families of children with ABI. Psychoeducation and consultation with health and education services supplemented this. A total of 105, often hard to reach families from right across the targeted region (Northern Ireland), accessed the project over a 7-year period. Children (0–12 years) had mostly experienced mild – moderate injuries and had thus missed out on services primarily aimed at hospitalized children with severe injuries. Nevertheless, complexity of need was found to be high. Mixed methods were used in a research pilot, pre – post evaluation, design.
Results: Of those who engaged with the programme for more than one consultation session (61%), outcomes on standardized scales suggested benefits for child behavior difficulties, child competencies and child and family quality of life. Whilst no control group was possible for ethical reasons, a thematic analysis of parental and child experiences suggested a direct association between programme participation and outcomes. Themes discerned related to the accessibility of the programme and the importance of a whole family approach to bolstering resilience and family empowerment. Levels of psychoeducation and consultation to health and education professionals were high and their qualitative data suggested benefits for their support of families.
Conclusions: We need to take our family-focused psychological interventions out of the clinic and into the community. Findings from the current study suggest a community-based family focused intervention programme shows promise for improving child and family outcomes.
128 Partnering with patients, caregivers and clinicians to determine research priorities in concussion: a James Lind Alliance (JLA) Priority Setting Partnership (PSP)
Martin Osmonda,b, Elizabeth Legacea, Roger Zemeka,b, Rhonda Corrella, Nick Reedd, Katherine Cowane, Dr. Peter Gillc,d, Colin Macarthurc,d
aCHEO Research Institute, Ottawa, Canada, bUniversity of Ottawa, Ottawa, Canada, cSickKids Research Institute, Toronto, Canada, dUniversity of Toronto, Toronto, Canada, eJames Lind Alliance, Southampton, United Kingdom
ABSTRACT
Importance: The opinions of patients, caregivers and frontline clinicians have rarely been considered in setting research priorities in concussion. Their perspectives may be valuable in identifying important areas in which to focus future research. The James Lind Alliance (JLA) has developed a method of bringing together patients, caregivers, and clinicians on an equal footing to Priority Setting Partnerships (PSPs) which identify, prioritize and raise awareness of important unanswered questions in a healthcare area. There have been over 150 JLA PSPs conducted to date but none in the area of concussion.
Objective: To collaboratively prioritize unanswered research questions in concussion from the perspective of patients, caregivers and healthcare professionals (HCP) who treat people with concussion.
Methods: The standardized JLA PSP method was used consisting of a modified Delphi technique and nominal group technique. Between Feb 16, 2021 and May 26, 2022, two online surveys and a virtual workshop were conducted. People of all ages, caregivers, and HCPs with experiences with concussion across Canada were included. A first survey gathered unanswered questions regarding concussion via open-ended questions. Survey responses were used to form summary questions which were then evidence-checked to ensure that they were unanswered. Those considered unanswered were distributed in a second Canada-wide survey for interim prioritization. The final top 10 questions were determined in a priority setting workshop attended by patients and HCP’s using a nominal group technique which is a well-established structured, multi-step facilitated group meeting technique.
Results: The first survey was completed by 249 respondents (145 patients/caregivers and 104 HCP) and generated 1,761 questions. These were combined into 80 summary questions. After evidence checking, 5 were deemed answered by research evidence. Sixteen questions submitted by only 1 or 2 respondents were removed. The remaining 59 unanswered questions were prioritized in the second survey which was completed by 989 respondents (662 patients/caregivers and 327 HCP). The top 17 ranked questions from the second survey were presented to the final workshop and prioritized by the participants into the top 10 questions. The top 10 questions focused on predicting prolonged recovery, determining the best approach to return to cognitive and physical activities, improving accuracy of diagnosis, uncovering the long-term impacts of concussion, and managing headache and disordered sleep.
Conclusions: This is the largest patient-informed, priority setting exercise in concussion to-date. This process identified the top 10 research priorities that matter most to patients, caregivers and clinicians. These questions can help focus and guide future research in order improve the health and well-being of people living with concussion.
129 Multidimensional profiles of participation after traumatic brain injury: a TBI model systems study
Shannon Juengsta,b, Stephanie Agtarapc, Umesh Venkatesand,e, Raj Kumarf, Kimberly Erlerg, Emily Evansg,h, Dr. Angelle Sandera,i, Daniel Klycej,k, Therese O’Neil-Pirozzig,l, Amanda Rabinowitzd,e, Lewis Kazisg, Joseph Giacinog, Tamara Bushnikm, Gale Whiteneckc
aTIRR Memorial Hermann, Houston, USA, bUT Houston Health Sciences Center, Houston, USA, cCraig Hospital, Englewood, USA, dMoss Rehabilitation Research Institute, Elkins Park, USA, eSigney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA, fIcahn School of Medicine at Mount Sinai, New York, USA, gMGH Institute of Health Professions, Boston, USA, hSpaulding Rehabilitation Hospital, Boston, USA, iBaylor College of Medicine, Houston, USA, jCentral Virginia Veterans Affairs Health Care System, Richmond, USA, kVirginia Commonwealth University, Richmond, USA, lNortheastern University, Boston, USA, mNYU Langone Health, New York, USA
ABSTRACT
Background and Objectives: Meaning of participation may vary across people and demographic groups, underscoring the need to consider both quantity (objectively measured) and quality (subjectively measured) dimensions of participation. To move beyond unidimensional formulations of participation, we conducted secondary analyses of a TBI Model Systems sub-study (N = 408) to: 1) characterize multidimensional societal participation profiles after moderate-severe traumatic brain injury (TBI) along objective (Frequency) and subjective (Satisfaction, Importance, Enfranchisement) dimensions; and 2) identify potentially meaningful targets for intervention and/or factors to inform risk stratification by examining personal, clinical, and environmental factors after TBI that differentiate these multidimensional participation profile groups.
Measures and Analyses: Multiaxial assessment of participation included the Participation Assessment with Recombined Tools-Objective and -Subjective questionnaires (Participation Frequency and Importance/Satisfaction, respectively) and the Enfranchisement Scale. Participants provided responses via telephone interview 1–15 years post-injury. Multidimensional participation profiles (classes) were extracted using latent profile analysis. Personal, clinical, and environmental factors that differentiated these profile groups were identified using multinomial logistic regression.
Results: We identified a 4-class solution as providing maximal statistical separation between participation profiles and being clinically meaningful based on profile demographic features. Profiles groups contained n = 111 (27%), n = 50 (12%), n = 198 (49%), and n = 49 (12%) participants, with class probabilities all >0.90. One profile group (49% of the sample) exhibited the “best” participation profile (high Frequency, Satisfaction, Importance, and Enfranchisement) and was also the most advantaged according to socioeconomic indicators. Other profile groups showed appreciable heterogeneity across participation dimensions. Age, race/ethnicity, education level, ability to drive, and urbanicity were features that varied between profiles. Multinomial regression results supported the importance of these differences, indicating that employment status, education (specifically less than high school versus high school education or more), current substance abuse, driving status, community type (urban, rural, suburban), and functional cognition (FIM Cognitive) significantly (p < 0.05) differentiated participation profile groups.
Conclusions: Societal participation is a critical, but inherently complex, TBI outcome that may not be adequately captured by a single index. Our data underscore the importance of a multidimensional approach to participation assessment and interpretation using profiles. Use of participation profiles may promote precision health interventions for community integration, with unmodifiable factors informing risk stratification and modifiable factors serving as potential targets for rehabilitation intervention.
130 The effects of blast- and impact-related concussions on persistent sleep problems
Samuel Chunga,b, Jennifer Beldinga,b, Elizabeth Harrisona,b, Robyn Englerta,b, Cynthia Thomsenb
aLeidos, Inc., San Diego, USA, bNaval Health Research Center, San Diego, USA
ABSTRACT
Background: Sleep problems are common in the military due in part to high operational tempo and exposures to stressors and/or trauma. Additionally, sleep problems may persist beyond deployment and develop into chronic conditions, increasing risks for adverse health outcomes. One potential contributor to sleep problems is concussion, which is a leading cause of morbidity among military personnel. Research suggests that several health outcomes are associated with both concussion and sleep, including repeated exposures to low-level blast (LLB), posttraumatic stress disorder (PTSD), depression, and alcohol use. Additionally, different mechanisms of injury resulting in concussion (e.g., high-level blast [HLB] or direct impacts to the head) have been found to play an important role in symptomology. However, limited research has examined whether concussion mechanisms of injury are also associated with differences in post-injury sleep problems among military personnel when accounting for these other factors. The present research examined whether concussion mechanism of injury (HLB vs. impact) affects the likelihood of sleep problems post-deployment.
Method: Data from U.S. enlisted Marines who completed the 2008 version of the Post-Deployment Health Assessment (PHDA) questionnaire upon return from deployment and the Post-Deployment Health Re-Assessment (PDHRA) approximately 6 months later were utilized (N = 64,464). Marines completed a modified version of the Brief Traumatic Brain Injury Screen, which was used to identify probable concussion and associated mechanism of injury (i.e., no concussion, HLB-induced concussion, or impact-induced concussion). The Primary Care PTSD Screen, Patient Health Questionnaire-2, and Alcohol Use Disorders Identification Test-Concise were used to identify probable PTSD, depression, and alcohol misuse, respectively. Military occupational specialty was used to identify occupational risk of LLB. Sleep problems were measured using a dichotomous item on both the PDHA (Time 1) and PDHRA (Time 2). Sleep problems at Time 2 were regressed on probable blast-induced concussions (vs. no concussions), probable impact-induced concussions (vs. no concussions), occupational risk of LLB, probable PTSD, probable depression, probable alcohol misuse, Time 1 sleep problems, and relevant interactions, while adjusting for gender and pay grade.
Results: With the exception of gender, all main effect predictors in the model were associated with greater likelihood of reporting sleep problems at Time 2. Sleep problems at Time 1 (OR = 3.43) followed by HLB-induced concussions (OR = 2.57) showed the strongest associations with likelihood of reporting sleep problems at Time 2. Additionally, the effect of HLB-induced concussions, but not impact-induced concussions, on Time 2 sleep was significantly elevated among those with PTSD and depression, respectively.
Conclusion: Marines reporting HLB concussions were more likely to report persistent sleep problems and this association was exacerbated by PTSD and depression. Additional monitoring and treatment for sleep issues may be necessary for those with blast-induced concussions compared to those with impact-induced concussions.
131 Effects of the response to the COVID-19 pandemic on assault-related head injury in melbourne: a retrospective study
Karen Caeyenberghsa, Juan Domingueza, Johnny Truonga, Jake Burnetta, Lata Satyena, Hamed Akhlaghib, Julian Stellac, Nick Rushworthd
aDeakin University, Burwood, Australia, bSt. Vincent’s Hospital, Melbourne, Australia, cGeelong Hospital, Geelong, Australia, dBrain Injury Australia, Sydney, Australia
ABSTRACT
Assault is the leading preventable cause of death, traumatic brain injury (TBI), and associated mental health problems. The COVID-19 pandemic has had a profound impact on patterns of interpersonal violence across the world. However, there is considerable heterogeneity in policies that countries have implemented to deal with the COVID-19 pandemic. The city of Melbourne, Australia, having gone through one of the longest and most stringent series of restrictions and lockdowns worldwide offers the best opportunity to assess the sustained effect of COVID-19 on the Who, Where and When of TBI resulting from assault. We utilized a retrospective cross-sectional design to analyze medical record data of assault victims who presented to the emergency department (ED) of St Vincent’s Hospital, an inner-city hospital in Melbourne, Australia. We examined changes in prevalence in the assault TBI group overall and subgroups of assault victims (such as domestic violence, random assault, and prison assault victims), comparing data from 19.5 months before and 19.5 months after March 16, 2020 (corresponding to the first day of restrictions in Melbourne). Moreover, we investigated differences driven by demographic factors (Who: including age group, sex, and nationality) and clinical variables (Where: assault location, and When: time of arrival to the ED and time from moment of injury until presentation at ED). We found the COVID-19 pandemic significantly affected the Where of assault-related TBI, with a shift in the location of assaults from the street to the home, and the increase at home being driven by random assaults on middle-aged adults (40–59 years old). In terms of the Who and When, while we found no overall effect of either (i.e., no differences in proportions of cases by assault subgroup, sex, age, nationality, arrival time at ED or time of presentation at ED from moment of injury), a subgroup analysis revealed a significantly lower number of middle-aged prison assault victims during the COVID period compared to the pre-COVID period. Looking at the data without partitioning into pre-COVID and COVID periods, we observed noticeably contrasting differences in the proportion of cases between random assault and domestic violence in terms of sex and alcohol consumption. Specifically, 86% of the random assault cases were males, whereas 74% of the domestic assault cases were females. Meanwhile, nearly half (44%) of the random assault victims reported alcohol consumption vs. a fifth (20%) of domestic violence victims. These findings will have direct implications for understanding the effects of sustained COVID-19 restrictions on interpersonal violence. They will also have implications for developing screening tools and better preventive and ameliorative interventions to deal with the sequelae of assault TBI (including mental health issues commonly associated with it), particularly in the context of future large scale health crises or emergencies.
132 Single-subject profiling in patients with traumatic brain injury using STREAMLINES
Karen Caeyenberghsa, Juan Domingueza, Alex Burmestera, Hamed Akhlaghib
aDeakin University, Burwood, Australia, bSt. Vincent’s Hospital, Melbourne, Australia
ABSTRACT
Neuroimaging techniques provide the means to yield in vivo mechanistic insights into symptoms in in patients with traumatic brain injury (TBI). Numerous studies have linked mental health deficits to different structural properties of specific brain regions, fiber bundles and/or brain networks in TBI patients using anatomical and diffusion MRI. While vital, these MRI studies have focused on group-wise comparisons of MRI metrics (i.e., patient vs control groups). However, clinicians need to perform diagnostic and prognostic inferences at the level of individual patients. To bridge this gap, we present proof of concept results of a novel electronic integrative, personalized translational medicine platform for neurological evaluation that we call STREAMLINES (Single-subjecT pRofiling of cognitivE impAirMents, affective deficits and structuraL braIN altErations and bio-Specimens). We will illustrate the use of STREAMLINES in patients with moderate to severe traumatic brain injury (TBI). We chose TBI to showcase the heterogeneity in patient profiles. STREAMLINES generates cross-sectional and longitudinal semi-automated profiles of single-subject in three different evaluation “streams”: cognitive/affective measures (Cognitive and Affective Stream), brain imaging measures (Brain Stream), and fluid biomarkers (Bio-Stream). The Cognitive and Affective Stream comprises our novel ecological momentary assessment (EMA) mobile app, which repeatedly measures and tracks cognitive functioning and mental health status within a patient’s natural environment over days to weeks to months. STREAMLINES’ Brain and Bio- Streams, use advanced processing pipelines to derive different brain and bio metrics to quantify subject-specific changes (e.g., gray matter integrity, white matter organization, connectome network properties, fluid biomarkers, etc.) and locates them relative to a reference cohort. This contextual information enables us to meaningfully, qualitatively and quantitatively, assess mental health problems and brain damage in single individuals. Moreover, we relate cognitive and affective metrics with brain and bio-metrics to uncover the underlying mechanisms of impairment (“Crossing the streams”). Our platform can handle between-patient heterogeneity reflecting fully and faithfully what happens in individual TBI patients. These resulting single-subject profiles can then be used by clinicians for integrative neuroscience-guided rehabilitation, assisting them in designing personalized rehabilitation programs (based on the unique lesion load and mental health characteristics of each patient), tracking their progress and adjusting care as necessary. Our STREAMLINES platform will enable clinicians to progress from the traditional paradigm of group-based comparisons of patients against controls, to a personalized medicine approach, and it will take us a step closer in the direction of translational integrative research that informs practice.
133 Acute care hospital blunt cerebrovascular injury screening practices after traumatic brain injury may have implications for rehabilitation outcomes
Yevgeniya Sergeyenkoa,b,c, Jessica Pan Conklind, Ford Voxb
aMossRehab Institute for Brain Health, MossRehab, Philadelphia, USA, bBrain Injury Rehabilitation Program, Shepherd Center, Atlanta, USA, cBrain Injury Medicine Fellowship, Emory University School of Medicine, Atlanta, USA, dCrawford Research Institute, Shepherd Center, Atlanta, USA
ABSTRACT
Introduction: Blunt cerebrovascular injury (BCVI) is primarily managed in acute trauma centers, but patients are subsequently referred to inpatient rehabilitation, where clinicians may be less aware of the necessity for BCVI screening.
Objective: To characterize the BCVI screening practices of acute care hospitals referring patients with traumatic brain injury (TBI) for rehabilitation; to identify individual and hospital variables which contribute to whether screenings are performed; to assess the relationships between BCVI screening and rehabilitation outcomes.
Design: Retrospective chart review.
Setting: A national rehabilitation hospital.
Participants: A consecutive sample of patients (n = 408) with TBI admitted for rehabilitation from April 2019 – April 2021.
Main Outcome Measures: BCVI screening performed at the acute care hospital and presence of positive findings.
Results: A total of 324 patients qualified for BCVI screening in acute care based on retrospectively applied best practices guidelines. Among the patients who qualified for BCVI screening, 222 patients (69%) received advanced imaging while 67 patients (27%) did not receive any screening. Of the patients who received any BCVI screening, 27% had positive findings. Level II trauma centers were significantly less likely to perform any screening of patients for BCVI (OR = 0.55; 95% CI = 0.35–0.85; p < 0.01). For patients who qualified for BCVI screening, presence of screening was associated with a shorter length of stay (t = 2.10, p < 0.05).
Conclusions: Trauma centers are highly variable in their BCVI screening of TBI patients, and patients treated at Level II trauma centers are less likely to receive screening. The BCVI incidence in patients with TBI may be higher than previously thought. Rehabilitation physicians responsible for surveillance and management of TBI complications should recognize that many patients admitted to acute inpatient rehabilitation may not have undergone BCVI screening.
135 Is brain injury linked to the development of chronic developing chronic neurological, psychiatric, cardiovascular, and endocrine diseases
Ross Zafontea
aSpaulding Rehab/Harvard Medical School, Boston, USA
ABSTRACT
A series of studies have noted an altered life span after brain injury. In specific, mortality has appeared increased from aspiration pneumonia and seizures after moderate and severe brain injury. Yet little work has been done to examine the role of chronic medical comorbidities among those with chronic brain injury.
We performed a comparative longitudinal data base study of over 9,000 controls and 9,000 persons with brain injury who were followed for over a decade. Only those with no prior medical comorbidities where included. Visit frequency bias was performed as an a pirori correction. In a comparative study matching those with brain injury and those without, we noted that patients with concussion, mild and moderate/severe TBI, are at significantly higher risk of developing chronic neurological, psychiatric, cardiovascular, and endocrine diseases in the chronic phase of TBI recovery compared to age, gender, sex matched uninjured controls. Data examining the comparative rates among orthopedic trauma controls will also be presented. We shall present time to onset data and hazards ratios for a series of medical and behavioral comorbidities. A brief discussion of the potential mechanisms and next analysis steps will be reviewed.
136 A survey to determine health utility states after a hypothetical traumatic brain injury: the influence of the personal history of severe traumatic brain injury on disability perceptions
Justin Weppnera,b,c, Melissa Wraya
aCarilion Clinic Brain Injury Center, Roanoke, USA, bVirginia Tech Carilion School of Medicine, Roanoke, USA, cEdward Via College of Osteopathic Medicine, Blacksburg, USA
ABSTRACT
Objective: This study aimed to determine the health utility states for persons with severe traumatic brain injury (TBI) and their caregivers versus able-bodied controls using the Extended Glasgow Outcome Scale (GOSE).
Methods: Three hundred persons with a history of severe TBI, 300 designated primary caregivers or family members, and 300 healthy age-matched controls enrolled in the study. Nine hundred participants completed the electronic survey using a standard gamble approach. Participants evaluated their preferences for GOSE health states one year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). GOSE health states were presented randomly for each participant. We asked participants to consider a hypothetical choice between (1) the certainty of continued life for GOSE 2 through 8 or (2) taking a gamble with two possible outcomes: (a) perfect health versus (b) immediate death. The gamble probabilities were initially set at the middle value (i.e., 50% immediate death, 50% perfect health) and then methodically adapted based on the participant’s responses until their health preference was determined for the GOSE state of interest by reaching the point of indifference between choices. If a participant identified a particular GOSE health state as worse than death, the choice became certainty of death or the gamble between perfect health and the health state valued as worse than death. The point of indifference was a negative value for health states rated as worse than death. Median health utility values for different GOSE states after TBI range from −1 (worse than death) to 1 (full health), with 0 as reference (death).
Results: Unadjusted health utility medians showed that participants rated lower GOSE states as having lower utility, though the relationship was not linear and intervals were unequal between health states. For healthy controls greatest decline in health utility was illustrated from GOSE4 to GOSE3, with the utility for GOSE3 and GOSE2 rated worse than death at −0.08 and −0.11, respectively. In contrast, persons with a history of severe TBI and their caregivers or family members showed no significant differences in the medical utility for GOSE 3–5. The greatest decline in health utility in the TBI population was illustrated from GOSE3 to GOSE2. The utility for GOSE2 was rated worse than death at −0.04 for those with severe TBI and −0.01 for caregivers and family members.
Conclusions: During acute care hospitalization, decision-making is seldom framed with a past experience of TBI. This work can address the quality of life after living with a TBI revealing that those with severe TBI and their family members see health utility in those with a severe disability which provides a metric to guide future research using the GOSE as a clinical research endpoint.
138 Insights from the individuals with traumatic brain injury exploring animal-assisted virtual reality material
Marjaana Raukola-Lindbloma,b,c, Jenni Huhtasalod
aSote Academy, University of Turku, Finland, 20100 Turku, Finland, bDepartment of Psychology and Speech-Language Pathology, University of Turku, 20100 Turku, Finland, cSkillful Interaction, 20100 Turku, Finland, dSatakunta University of Applied Sciences, Faculty of Technology, 28130 Pori, Finland
ABSTRACT
Background: Traumatic brain injuries (TBI) followed by accidents are common and lead to long-term impacts on social well-being and quality of life. Animal-assisted interventions are known to influence positively on social interaction and participation. For some individuals with TBI, it may be impossible to participate in real-life animal-assisted interventions for many reasons, e.g., allergies, physical impairments, or lack of professional animal-assisted therapy providers. A specific virtual reality (VR) material may be created with animal-assisted content to enable feelings of presence and inclusion in animal-assisted activities. There is a lack of animal-assisted VR material and experiences of its usefulness and effectiveness in rehabilitation. To create VR material that meets the needs of individuals with TBI, we need to include them in the co-creation process. There is currently not enough knowledge of how individuals with TBI perceive VR application with animal-assisted material.
Objectives: This pilot trial takes place before going forward with developing animal-assisted VR material, interventions, and studies considering this. We aim to collect experiences and insights from the volunteered individuals with TBI who have explored the produced preliminary animal-assisted VR material. This preliminary animal-assisted VR material includes, for example, the interaction of horses and the Finnish countryside. In addition, multisensory stimuli, such as the sounds of animals and the possibility to touch related materials, will be provided.
Methods: Selected preliminary animal-assisted VR materials will be shown to a minimum of five volunteered individuals with TBI with multisensory material related to animal content. Their experiences and insights will be collected using a questionnaire and interview. The comments will be pieced together and organized thematically. The development of animal-assisted VR material will continue in the co-creation process based on their feedback.
Results and Conclusion: At this conference, we will present experiences and insights from individuals with TBI who have explored the preliminary animal-assisted VR material and multisensory material related to that.
We expect beneficial insights from the individuals with TBI to develop animal-assisted VR material for further interventions. Based on earlier studies, we hypothesize that most individuals with TBI are interested in this material and may see it as beneficial. Also, some negative experiences are expected. The updated results and conclusions will be presented at the conference.
139 Implementing home-based light therapy for fatigue and sleep following acquired brain injury: a pilot trial
Jennie Ponsforda,b, Laura Connollya,b, Shantha Rajaratnama,c, Jade Murraya,b, Gershon Spitza,b, Steven Lockleya,c
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia, cDivision of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital; Division of Sleep Medicine, Harvard Medical School, Boston, USA
ABSTRACT
Fatigue and sleep disturbance are disabling problems following brain injury and there are no established treatments. Building on our previously demonstrated efficacy of blue light delivered via a lightbox in reducing fatigue and daytime sleepiness after TBI, this study evaluated the efficacy of a novel in-home light intervention in alleviating fatigue, sleep disturbance, daytime sleepiness and depressive symptoms after brain injury, and in improving psychomotor vigilance and participation in daily productive activity, following injury. The impact of exposure to a dynamic light intervention (Treatment) was compared to usual lighting (Control) in a randomized within-subject, crossover trial. Outcomes were fatigue (primary outcome), daytime sleepiness, sleep disturbance, insomnia symptoms, psychomotor vigilance, mood and activity levels. Participants (N = 24, M± SDage = 44.3 ± 11.4) had mild-severe TBI (n = 19) or stroke (n = 5) >3 months previously, and self-reported fatigue (Fatigue Severity Scale ≥4). Following 2-week baseline, participants completed each condition for 2 months in counter-balanced order, with 1-month follow-up. Treatment comprised daytime blue-enriched white light (CCT >5000 K) and blue-depleted light (<3000 K) 3 hours prior to sleep. Random-effects mixed-model analysis showed no significantly greater change in fatigue on the Brief Fatigue Inventory during treatment, but trended toward a medium effect size of improvement (p = 0.33, d = −0.42). There were significantly greater decreases in sleep disturbance (p = 0.004), insomnia symptoms (p = 0.036), reaction time (p = 0.004) and improvements in productive activity (p = 0.005) at end of treatment relative to Control, with large effect sizes (d > 0.80). Changes in other outcomes were non-significant. In conclusion, this pilot study provides preliminary support for in-home dynamic light therapy to address sleep-related symptoms in acquired brain injury.
140 Comparing adapted cognitive behavioral therapy with health education for sleep disturbance and fatigue following acquired brain injury: a randomized controlled trial
Jennie Ponsforda,b, Lucy Ymera,b, Dana Wongc, Kate Frenchama,b, Natalie Grimaa,b, Joanna Tranb, Sylvia Nguyenb, Moira Jungeb, Jade Murraya,b, Gershon Spitza,b, Adam McKaya,b
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia, cSchool of Psychology and Public Health, Latrobe University, Melbourne, Australia
ABSTRACT
Sleep disturbance and fatigue are amongst the most debilitating symptoms following acquired brain injury (ABI), and are associated with poorer functional outcomes. Cognitive behavioral therapy (CBT) holds promise as a treatment for sleep and fatigue problems after ABI, although comparison with an active control is needed to establish efficacy. We have compared adapted CBT for sleep disturbance and fatigue (CBT-SF) with a health education intervention (HE) to control for nonspecific therapy effects. In a parallel group, pilot randomized controlled trial, we have analyzed data for 51 individuals with traumatic brain injury (n = 22) and stroke (n = 29) and clinically significant sleep and/or fatigue problems. They were randomized 2:1 into 8-weeks of either CBT-SF (n = 34) or HE (n = 17), both adapted for cognitive impairments. Participants were assessed at baseline, post-treatment, 2-months and 4-months post-treatment. Primary outcome was the Pittsburgh Sleep Quality Index, with secondary outcomes including measures of fatigue, sleepiness, mood, quality of life, activity levels, self-efficacy and actigraphy sleep measures. Results for analysis of data from the 51 participants showed that CBT-SF lead to significantly greater improvements in sleep quality compared to HE, during treatment and at 2-months [95% confidence interval (CI) – 24.83 to – 7.71]. There were also significant reductions in fatigue after CBT-SF maintained at all time points, not evident in HE (95% CI – 1.86–0.23). HE showed delayed improvement in sleep quality at 4-months post-treatment and depression (95% CI −1.37 – −0.09) at 42-months post-treatment. Significant gains in self-efficacy (95% CI 0.15–0.53) and mental health (95% CI 1.82–65.06) were also evident after CBT-SF. This study has continued and we have recently completed recruitment of 109 individuals with TBI (n = 45, 41.2%) or stroke (n = 64, 58.8%), of whom 52.3% were males, seen either in person (n = 28, 25.7%), or via telehealth (n = 81, 74.31%). Updated findings will be presented. Findings to date suggest that CBT-SF can be an effective treatment option for sleep disturbance and fatigue after ABI, over and above HE. HE may provide delayed benefit for sleep, possibly through improved mood.
141 Workers’ compensation patients with concussions resemble concussions from motor vehicle accidents more than sport-related injuries
Abigail Bissonb, M Nadir Haidera, Jacob McPhersona, Andrew Nowakc, Barry Willera, Haley Chizuk, John Leddya
aUniversity at Buffalo, SUNY, Buffalo, USA, bPennsylvania State University, State College, USA, cCentral Michigan University, Mount Pleasant, USA
ABSTRACT
Prior research suggests that patients on workers’ compensation insurance report worse mood symptoms and outcomes than those on commercial insurance, even when they are comparable in their post-concussion symptom burden. We conducted a retrospective chart review of patients with acute and persistent concussions seen at a university-affiliated concussion clinic. We compared their self-reported mental and physical health on the Short Form 12 (SF-12) at their initial and final visits. Three hundred and thirty-seven patients were included in the analysis, of which 96 were on workers’ compensation (WC, 44.7 ± 13 years, 48% male, 144.8 ± 206 days since injury, 364.7 ± 329 days to recovery), 142 were sport-related concussions (SRC, 17.3 ± 7 years, 60% male, 43.7 ± 108 days since injury, 114.0 ± 191 days to recovery), 41 were from motor vehicle accidents (MVA, 41.0 ± 14 years, 39% male, 314.0 ± 442 days since injury, 515.5 ± 496 days to recovery) and 56 were from other causes such as falls and assaults (Other, 35.7 ± 21 years, 30% male, 68.6 ± 119 days since injury, 168.8 ± 192 days to recovery). WC patients reported significantly worse mental function at their initial (41.1 ± 11.7 vs. 49.4 ± 10.7, p < 0.001) and final visits (45.0 ± 11.0 vs. 53.4 ± 8.6, p < 0.001) than SRC patients, but did not significantly differ from MVA patients at the initial (38.8 ± 9.6, p = 0.263) or final visits (41.3 ± 10.2, p = 0.069). Similarly, WC patients reported significantly worse physical function at their initial (33.9 ± 8 vs. 40.6 ± 8.2, p < 0.001) and final visits (36.7 ± 9.4 vs. 48.9 ± 7.5, p < 0.001) than SRC patients. However, WC patients reported better physical function than MVA patients at their initial (30.7 ± 7.0, p = 0.029) and final visits (32.5 ± 7.9, p = 0.013). There were no differences between groups when comparing improvement in mental function from initial to final visit (p = 0.790), but SRC patients reported a greater improvement in their physical function (8.2 ± 9.6) than WC (3.01 ± 8.6) or MVA patients (1.9 ± 9.3, p < 0.001) during treatment. SRC patients also had fewer clinical visits (3.5 ± 2) than WC (8.2 ± 5) or MVA (9.6 ± 6, p < 0.001) patients. Duration of care had a moderate negative correlation with mental (r = −0.311, p < 0.001) and physical (r = −0.377, p < 0.001) function at the time of clearance in the entire sample. Our results suggest that after a concussion, WC patients have worse mental function scores but similar physical function scores and a similar clinical course as experienced by patients with concussion after an MVA than from SRC.
142 An outlier analysis for acute blood biomarkers of mild traumatic brain injury
Malla Mononena, BM Otto Korhonena, Jussi Postia, Mehrbod Mohammadiana, Professor Olli Tenovuoa, Professor David Menonb, Virginia Newcombeb, Peter Hutchinsonb, Henrik Zettenbergc, Kaj Blennowc, Jean-Charles Sanchezd
aUniversity of Turku, Turku, Finland, bUniversity of Cambridge and Addenbrooke’s Hospital, Cambridge, United Kingdom, cUniversity of Gothenburg, Gothenburg, Sweden, dUniversity of Geneva, Geneva, Switzerland
ABSTRACT
Introduction: Blood-based biomarkers are being actively developed to aid in the diagnostics and prognostication of mild traumatic brain injury (mTBI). In order to assess their clinical usability, one needs to know factors that may cause abnormal values, which might cause erroneous interpretations and lead to wrong clinical decision-making.
Methods: We analyzed the blood levels of eight protein biomarkers (GFAP, S100B, NfL, H-FABP, IL-10, t-tau, amyloid B40, and amyloid B42) in a prospectively collected cohort of patients with an acute mTBI (n = 115), within 24 hrs of admission to emergency department in the EU funded TBIcare study. In addition, respective analyses were done from controls with an acute orthopedic injury without any head trauma suspicion (n = 40). The patients were classified on basis of CT imaging (normal vs. abnormal) and outcome (Glasgow Outcome Scale Extended 8 or <8). Biomarker values beyond ± 1.5 IQR were classified as outliers. In order to find out the possible reasons for abnormally high or low values, the medical records were gone through in detail in a team meeting.
Results: Altogether 36 patients (31%) with mTBI showed abnormal values in some biomarker in regard to the CT reference group and 32 patients (28%) in regard to the outcome reference group. Of the controls, 12 (30%) showed abnormal values in one or more biomarkers. In many patients, several biomarkers (up to six) were abnormal. All of the outliers were abnormally high. A clinical analysis provided a logical explanation for most abnormal values, except in case of tau and amyloid biomarkers. These explanations included more serious TBI based on imaging (esp. for GFAP), injuries to other organs (especially thoracic injuries in case of H-FABP and multitrauma in case of IL-10 and S100B), or time from injury to sampling (esp. in case of NfL). Also, age and earlier neurological conditions emerged as apparent explanations for some abnormal values. Respective causes were also found in controls, where especially preexisting neurological diseases caused abnormal values for, e.g., GFAP and NfL.
Conclusions: In order to use blood-based biomarkers to aid in the acute clinical assessment of an mTBI, one has to know and take into consideration other health issues that might influence the level of a certain biomarker. This information is vital for proper decision-making. Also, temporal factors have to be taken into account.
143 Upper limb robotic as adjuvant to neurorehabilitation for acquired brain injury adult population
Norhamizan Hamzaha, Nor Asiah Muhamadb, Nur Azah Hamzaidc
aRehabilitation Medicine, Universiti Malaya, Kuala Lumpur, Malaysia, bNational Health Institute, Ministry of Health, Kuala Lumpur, Malaysia, cFaculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
ABSTRACT
This study objectives were i) to quantify the application of robotic ArmMotus™ M2 in neurorehabilitation program and ii) to identify motor outcome measure(s) that translate to clinical significance. The inclusion criteria included adult aged more than 18 years old, diagnosed with acquired brain injury (stroke/traumatic brain injury) of less than one year, with arm paresis MRC power grading of ≥ 2/5 and Montreal Cognitive Assessment total score of ≥ 26/30. The exclusion criteria were limb pain, limb spasticity MAS grade ≥ 2 and open wound on the chosen limb. Intervention method: ArmMotus™ M2 training program to include motor coordination and isometric training with multiple motor training modes (active, assistive and passive) interactive games, combined with physical therapy (stretching exercises, strengthening and functional training). Total treatment duration was 1 hour/session. The outcome measures were i) mean force (N) difference and ii) affected limb range of motion (ROM) degree change. Results: Sixty-two (n = 62) participants were recruited over 8 months period; 92% were new stroke cases with the male: female ratio of 1:2. The mean age was 51.82 ± 14.27 years old (p = 0.38). Affected upper limb distribution: right upper limb = 28; left upper limb = 24; bilateral upper limbs = 7. single arm motor coordination was the most selected training program (82%). Single mode was preferred, either active = 24%; passive = 26% or assistive = 11%. Combined games were applied more (69%) per participant/session. Mean session was 2 ± 1.5 at 60 minutes/session. The treatment impact (force difference) for active mode was small (Cohen’s d = 0.24) and for assistive mode was large (Cohen’s d = 0.62), both achieved by the 5th session. Less participants (14%) required passive mode treatment by the 8th session. ROM values were variable and highly dependent on the gamified program. This study concluded that i) the application of robotic ArmMotus™ M2 in neurorehabilitation has a potential as an adjuvant treatment and ii) force difference had the most impact as an outcome measure in the active and assistive motor training applied at weekly frequency for at least 8 sessions in the ABI population of <1 year diagnosis.
144 Critical incidents in adolescents’ return to school following a concussion
Rachel Kinga, Marissa Halla, William McKeea
aUniversity Of British Columbia, Vancouver, Canada
ABSTRACT
Objective: As many as 33 million children worldwide experience concussion each year (Davis et al., 2017). Children are more susceptible to concussion than adults and at greater risk for long-term consequences following concussion (Hachem et al., 2016; Karlin, 2011; Sady et al., 2011). The wide-ranging symptoms of childhood concussion are all likely to affect multiple dimensions of student functioning at school (Ransom et al., 2015). Return-To-Learn (RTL) plans have been developed to minimize symptom exacerbation and long-term consequences by young people over-exerting themselves when they return to school and to provide the supports needed for them to be able to reengage with school while recovering (McAvoy et al., 2020). However, RTL plans are not yet mandated in Canada and are not implemented in many parts of the country. Additionally, educators report many challenges with trying to implement RTL planning (Sarmiento et al., 2019; Russel et al., 2017). In order to improve the experience of returning to school for those students who are recovering from a concussion, it is important to understand the experience of the students themselves. While there are many studies describing challenges students may face reengaging in school life, information on the experience of students returning to a learning environment following a concussion is sorely lacking. This study explores the experiences students perceive as helpful, unhelpful, and those they wish had been different in their return to school.
Participants and Methods: Six high school students who had experienced concussion (at least six months prior), and had subsequently reengaged with school life, were recruited from the greater Vancouver area, BC. Participants engaged in semi-structured interviews, in accordance with the Enhanced Critical Incident Technique. Transcripts were thematically analyzed using an iterative technique.
Results: Participants identified the majority of influential factors as both potential barriers and potential facilitators in their reintegration into school life, depending on the participant’s context (Staff Knowledge, Understanding and Attitude to Concussion; Impact of Environmental Context; Inclusion/Exclusion from Important Activities; Impact of Academic Context; and Quality and Responsiveness of Planning). These factors were also those that participants identified on their “Wish List” for improvement. Participants identified Social Support as an additional facilitator, and Change in Capacity and Negative Psychological Impact as additional barriers to reengaging in school life.
Conclusions: This exploratory study considered the factors that influence successful reengagement in school life for adolescents post-concussion. Through engaging the student perspective, avenues for improving the experience of students reintegrating into school after concussion have been identified. Additionally, this study provides further evidence of the importance of use of RTL plans in supporting the reintegration of adolescents into school following a concussion.
146 Covert self-processing in patients with a disorder of consciousness
Fabrice Ferrea,b,c, Lizette Heineb, Edouard Naboulsia, Florent Gobertd, Maude Beaudoine, Frédéric Daillerd, William Buffièresa, Eng Alexandra Corneyllieb, Benjamine Sartona,c, Béatrice Riua, Jacques Luautée, Stein Silvaa,c, Fabien Perrinb
aIntensive Care Unit, Purpan University Teaching Hospital, Toulouse, France, bCentre de Recherche en Neurosciences de Lyon (CRNL), CAP Team, UCBL - Inserm U1028 - CNRS UMR5292, Bron, France, cToulouse NeuroImaging Center (ToNIC) laboratory, UMR INSERM/UPS 1214, Toulouse, France, dRéanimation Neurologique et Soins Continus, Hôpital Pierre Wertheimer, HCL, Bron, France, eService de Médecine Physique et de Réadaptation Neurologique, Hôpital Henry Gabrielle, Saint Genis Laval, France
ABSTRACT
It is now clearly established that patients with acquired disorders of consciousness (DoC) can evoke cerebral responses to active paradigms, despite the absence of behavioral sign of conscious processing.
Altogether, these studies mainly focused on the preservation of high-level cognitive markers, but did not specifically investigate lower but key-cognitive functions to consciousness emergence, such as the ability to use first-person perspective. Indeed, it could been argued that the preservation of the self (consciously or unconsciously) can reflect the ability to recover consciousness, independently of the clinical status. To test this hypothesis, we sought to explore to which extent patients diagnosed with DoC are able to perform self-processing and whether the presence of this cerebral index is a cognitive prerequisite for the recovery of consciousness.
Using bedside electroencephalographic recordings, we acquired the brain response to the subject’s own name (SON) and to unfamiliar other first names (OFN) in a large cohort of 120 severely brain damaged patients of whom 112 could be analyzed for the primary endpoint (mean age ± SD = 46 ± 18.3 years, sex ratio M/F: 71/41), who were either in coma (n = 38), unresponsive wakefulness syndrome (UWS, n = 30) or minimally conscious state (MCS, n = 44), according to the Coma Recovery Scale-Revised (CRS-R) score.
Overall, 33 DoC patients (29.5%) evoked an individual and significant discriminative brain response to the SON as compared to OFN. The detection of the electrophysiological response was similar between coma (28.9%), MCS (23.3%) and UWS (34.1%) patients (p = 0.61). The presence of a brain response to the SON, in the 72 survivors’ patients, predicts patient’s behaviorally overt consciousness recovery (exit-MCS) or improvement at 6 months with high specificity (respectively 85% and 82%) and high positive predictive value (respectively 75% and 81%), but with low sensitivity (respectively 27% and 24%) and negative predictive value (respectively 41% and 25%).
About 30% of severely brain-damaged patients suffering from DOC are capable to process salient self-referential auditory stimuli, even in case of absence of behavioral detection of conscious processing. We suggest that this covert brain ability is both an accurate index of self-processing and a prerequisite for consciousness recovery.
147 An exploration of the associations between traumatic brain injury and domestic violence within women in a UK Prison
Sarah Turnera, Sara Da Silva Ramosa, Jocelyn Gaynora, Harriet Paula
aThe Disabilities Trust, Burgess Hill, United Kingdom
ABSTRACT
Studies investigating the prevalence of traumatic brain injury (TBI) in female offenders, and its relationship with being a victim or a perpetrator of violence, are scarce but there is indication that TBI is highly prevalent in this population, and that it is linked to violence. This paper reports a retrospective analysis of routine clinical evaluation data relating to TBI, domestic violence (DV), mental health, and offending behavior. Results suggest that both TBI and DV contribute to poorer mental health and a heightened risk of recurrent, violent offenses. The nature of these relationships should be investigated further so as to provide insight to the difficulties faced alongside practice change recommendations to domestic abuse professionals working with survivors of DA who have a TBI.
148 Making a case to fund on-site collaboration and training of local people, to support an individual with a TBI in gaining independence and participation in meaningful and realistic life activities. Overcoming cultural, language, family, geographical and socioeconomic barriers. A case study of collaboration between Canada and Hungary
Natalie Kalymona, Siimone Friedmanb
a365 Rehab, Toronto, Canada, bTherapy Spot, Toronto, Canada
ABSTRACT
Background: Funding for the training of local people in rural, remote areas is an example of an access to care issue that rehabilitation teams face. Here we report the case of JS, a 52-year-old, single father, was involved in a motor vehicle accident in February, 2020, and experienced a catastrophic TBI. After being released from hospital, unable to work, living alone, and with no one to care for him, he was forced to leave his home and his young daughter, and go back to Hungary to live with and be cared for by his sister. In a small rural village, 3 hours from Budapest, JS reported feeling despondent, depressed, uncertain about his future, about his lack of purpose, and whether he would ever be able to return home.
Objectives: To provide brain injury rehabilitation that would improve JS’s mood, by giving him the tools and compensation skills needed to build a strong relationship with his daughter remotely, and improve his independence, ambulation, communication, and cognition for a purposeful and meaningful life in Hungary.
Methods: With his funding source in Canada, his interdisciplinary team investigated local Hungarian rehabilitation resources. Given his rural location, access to care was limited. Remote teaching by his team ensued. With the help of an interpreter, education and training of a local family friend occurred to take on the role of a personal support worker (PSW). Checklists and templates were created to encourage a greater level of independence in the home. After one year of remote learning, improvements were noted at the Activity level of the World Health Organization’s International Classification of Functioning, Disability & Health, (ICIDH-2); however, JS continued to lack life purpose and meaning. As such, a proposal was submitted to his Canadian Funding source to travel to Hungary, to provide on-site face-to-face education to improve interaction with his daughter, develop participation level (ICIDH-2) community goals, train, collaborate with local Hungarians, to help him integrate into the community and gain independence and purpose in life.
Results: Remote learning over zoom can provide gains at the impairment and activity level (as per ICIDH-2). However, when an individual lives in rural areas, remote virtual teaching doesn’t allow for exploration of community resources and it, therefore, limits purposeful, meaningful, participation-level outcomes.
Conclusion: We provide case-level evidence that virtual care has limitations when providing rehabilitation for TBI and advocate for in-person collaboration to train local people to help the affected individuals. When socio-cultural and geographical barriers prevent effective delivery of remote TBI rehabilitation programs, we believe that, when clinically indicated, funding agencies should provide resources for rehabilitation teams to travel on-site to target participation-level goals.
149 Using social cognitive theory to predict physical activity participation and quality of life for individuals with traumatic brain injury
Erin Snappa, Jeffrey Martina, Whitney Mooreb
aWayne State University, Detroit, USA, bEast Carolina University, Greenville, USA
ABSTRACT
Background: Traumatic brain injury (TBI) often results in lifelong deficits in many areas of functioning. Physical activity (PA) research in this population has shown many benefits, including improved physical function, mental health, cognitive function, and the amelioration of other specific TBI deficits. Research using theoretical frameworks is needed to better understand how to utilize PA to improve quality of life (QOL) following a TBI. Social Cognitive Theory (SCT) is a commonly used theoretical framework to study PA for individuals with TBI, yet few researchers have included all variables that represent the major psychosocial constructs (i.e., self-efficacy, self-regulation, outcome expectations and social support) in SCT in a single study.
Purpose: This study examined a SCT model to predict PA participation and how PA participation predicts QOL for individuals with TBIs. We hypothesized that all SCT factors would predict PA participation and that PA participation would mediate the relationship from SCT variables to QOL.
Methods: Participants of all TBI severities were recruited through social media and assessed via self-report battery about their TBI self-efficacy (SE), exercise SE, positive and negative social support (SS), exercise barriers, outcome expectations, PA engagement and QOL after TBI. Structural equation modeling was used to evaluate a fully mediated model. RESULTS: The results demonstrated that there were no significant direct relationships from the SCT factors to PA nor were there any significant indirect effects from the SCT factors to QOL through PA. However, there were multiple significant direct effects from the SCT factors to QOL, including TBI-SE 95%CI (0.690, 1.233), Negative SS 95%CI (0.347, 0.821), and Outcome Expectations 95%CI (0.194, 0.735). The final model fit was ∆χ2(459) = 849.324, CFI = 0.910, TLI = 0.901, SRMR = 0.087, RMSEA = 0.066, 90%CI [0.059, 0.073] with the model accounting for 56% of the variance in QOL.
Conclusion: Though SCT factors did not predict PA as hypothesized, the direct relationships to QOL provide important insight for improving life following TBI. Factors such as confidence in management of TBI symptoms, negative feedback from support systems, and higher expectations for PA engagement related to higher QOL. Future researchers should evaluate why SCT factors in the current study did not relate to PA, but also, consider utilizing the related factors as ways to continue improving QOL in intervention studies.
150 A survey of physician perceptions of disability outcomes after hypothetical traumatic brain injury
Justin Weppnera,b,c, Melissa Wraya
aCarilion Clinic Brain Injury Center, Roanoke, USA, bVirginia Tech Carilion School of Medicine, Roanoke, USA, cEdward Via College of Osteopathic Medicine, Blacksburg, USA
ABSTRACT
Objective: This study aimed to determine physician health utility states of the Extended Glasgow Outcome Scale (GOSE).
Methods: This was a cross-sectional web-based online convenience sampling adaptive survey of board-certified physicians from specialties including neurology, neurosurgery, surgical critical care, pulmonary critical care, and physical medicine & rehabilitation. Using a standard gamble approach, participants evaluated their preferences for GOSE health states one year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). GOSE health states were presented randomly for each participant. We asked participants to consider a hypothetical choice between (1) the certainty of continued life for GOSE 2 through 8 or (2) taking a gamble with two possible outcomes: (a) perfect health versus (b) immediate death. The gamble probabilities were initially set at the middle value (i.e., 50% immediate death, 50% perfect health) and then methodically adapted based on the participant’s responses until their health preference was determined for the GOSE state of interest by reaching the point of indifference between choices. If a participant identified a particular GOSE health state as worse than death, the choice became certainty of death or the gamble between perfect health and the health state valued as worse than death. The point of indifference was a negative value for health states rated as worse than death. Median health utility values for different GOSE states after TBI range from −1 (worse than death) to 1 (full health), with 0 as reference (death).
Results: Of the 550 eligible participants, 528 (96%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated worse than death, though the relationship was nonlinear. The greatest decline in health utility was illustrated from GOSE4 to GOSE3, with the unadjusted health utility medians for GOSE3 and GOSE2 rated worse than death at −0.1 and −0.19, respectively.
Conclusions: During acute care hospitalizations, decision-making may be framed by physician perceptions of disability and past experiences. The health utility medians for physicians were lower than in previous surveys of healthy volunteers and those with severe TBI. Median health utility scores in this study reported severe disability (GOSE3) as a fate worse than death, and this bias may impact physician prognostication discussions. While GOSE3 and GOSE2 are generally considered poor outcomes, physicians reporting lower health utility means than the general population should consider this bias during prognostic discussions. Despite the best intentions of physicians to provide equal treatment to all, health utility disparities linger and may lead to increases in morbidity and mortality for some. Improving communication and decision-making between physicians and families should reduce discordance in health utility perceptions and find ways to target belief differences.
151 Predictors of externalizing behavior outcomes following pediatric stroke
Alyssia Wilsona, Nataly Beribiskya, Mary Desrochera, Robyn Westmacottb
aYork University, Toronto, Canada, bThe Hospital for Sick Children, Toronto, Canada
ABSTRACT
It is well-recognized that behavioral problems following pediatric stroke are common. These have not been well characterized as research has focused largely on prevalent concerns of motor and cognitive outcomes in perinatal and childhood stroke populations. The most commonly reported behavioral concern, reported in about half of child following pediatric stroke, is increased difficulties with attention such as impulsivity, learning difficulties, and anxiety. Research has also reported high levels of behavior problems at home (44%); which have been found to be correlated with executive functions. The purpose of this study was to evaluate the relationship between externalizing behavior and executive function following pediatric stroke.
Methods: This retrospective study included 339 children with pediatric ischemic stroke who were identified upon enrollment in the Canadian Pediatric Stroke Registry at the Hospital for Sick Children between 2000 and 2019. We observed the prevalence of externalizing behaviors and executive function and the correlation between them using parent rating forms of the Behavioral Assessment System for Children (BASC) and the Behavior Rating Inventory of Executive Function (BRIEF). Associated neurological and clinical factors were also examined as predictors of behavioral outcomes.
Results: No differences were found between externalizing behavior or executive function scores between individuals who suffered a perinatal (n = 94) or childhood (n = 116) stroke, except for the shift subscale which had higher T-scores in perinatal (M = 55.83) than childhood (M = 50.40). When examined descriptively, there were more children with clinically elevated hyperactivity than expected (observed = 9.62%, expected = 2%). Similarly, children with stroke endorsed greater problems on the BRIEF behavior regulation and metacognition indices. Externalizing behaviors were correlated moderately to strongly with executive function measures (r = 0.42 to 0.74). When examining neurological and clinical predictors of externalizing behaviors, only female sex was predictive of increased hyperactivity (p = 0.004), whereas age at stroke, presence of seizures at onset, and stroke location were not associated with any behavioral outcomes.
Conclusions: We found that children with stroke are more likely to experience clinically elevated levels of hyperactivity than expected in a normal population. This finding brings an important narrative to the conversation surrounding significant increases in ADHD following stroke, which focus largely on attention (i.e., internalizing) outcomes. Although previous research has shown high levels of parent concern and behavioral problems, the level of behavioral problems reported in this study suggested that externalizing symptoms fall within the normal range. Although female sex predicted higher hyperactivity, stroke related variables, such as seizure comorbidity, age at stroke, and stroke location were not predictive of behavior outcomes. Future research should focus more on the influence of demographic variables, general health, and family mental health on behavioral outcomes in children following stroke.
152 Project HOPE: clinician perspectives on the usability and acceptability of a family-led, video-based, peer support resource for families of children and adolescents with acquired brain injury
Taylor Jenkina,b, Marnie Drakea,b, Kate Heinea, Penelope Analytisa,b, Michael Kendalla, Adam Scheinbergb,d,e, Sarah Knightb,d,e
aHeads Together for ABI, Melbourne, Australia, bMurdoch Children’s Research Institute, Melbourne, Australia, cMelbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia, dDepartment of Pediatrics, The University of Melbourne, Melbourne, Australia, eVictorian Pediatric Rehabilitation Service, Royal Children’s Hospital, Melbourne, Australia
ABSTRACT
Background: Pediatric acquired brain injury (ABI) can have significant impacts on children/adolescents across cognitive and functional domains, and their families often experience acute and long-term challenges, including distress, anxiety, and changes in family functioning. During rehabilitation, families often desire opportunities to connect with peers who have shared similar experiences. However, such opportunities are often unavailable and many families report unmet peer support needs. Heads Together Online Peer Education (HOPE) is an online, video-based peer support resource developed by families with lived experience of ABI in collaboration with clinicians and researchers. HOPE aims to provide information, hope, and support to families adjusting to living with ABI. Users navigate through videos of families sharing their personal stories of pediatric ABI. While understanding families’ perspectives of the resource’s usability is crucial, it is also important that rehabilitation clinicians are engaged in this process to support its adoption in clinical care during the early stages post-ABI.
Objective: This study is part of a larger iterative knowledge translation program aiming to develop and implement HOPE for families impacted by pediatric ABI in Australia. In this mixed methods study, we aimed to understand clinicians’ perspectives of the usability and acceptability of HOPE at a statewide interdisciplinary pediatric rehabilitation service, with a focus on content and online delivery.
Methods: Clinicians from a state-wide interdisciplinary rehabilitation service were identified and invited to participate using purposive sampling. Participants accessed the HOPE website over four to six weeks. Each participant completed the System Usability Scale and participated in a semi-structured interview at follow-up. Interview transcripts were analyzed using inductive content analysis.
Results: Thirteen clinicians from a range of discipline backgrounds and levels of pediatric ABI rehabilitation experience (range 1–30 years; 12 female) participated. Overall, participants rated the usability of the website as ‘good’ (mean rating: 81.7/100.0). Several participants reported minor issues in navigating the website. All participants perceived that the delivery format was engaging and the content relevant to the families that they work with in rehabilitation.
All participants shared that they would recommend HOPE to families of children/adolescents with ABIs, but that the decision to introduce the resource would be best made on a case-by-case basis in consultation with the interdisciplinary rehabilitation team. They also reflected on factors that would influence this decision, such as timing post-injury, rehabilitation stage, and psychosocial factors including family adjustment.
Conclusions: This study provides preliminary support for the usability and acceptability of an online, video-based peer support resource for families of children/adolescents with ABI at a state-wide pediatric rehabilitation service from the perspective of clinicians. Further investigation is required to explore the resource’s usability and acceptability with families in the early stages post-ABI, as well as its efficacy in improving family outcomes.
153 Working with mothers with acquired brain injury in an irish context: challenging their unequal status and their dual identity as mothers who continue to give care and disabled people who receive care
Philomena Butlera
aUniversity College Dublin, Dublin, Ireland
ABSTRACT
In Ireland, approximately 19,000 people sustain a brain injury annually, including approximately 8,000 people treated for a stroke (ABI Ireland, 2020). The National Rehabilitation University Hospital (NRH) is the national tertiary center for inpatient rehabilitation for adults with Acquired Brain Injury (ABI). In 2021, the NRH worked with 92 inpatients on the (adult) brain injury programme and 82 on the (adult) stroke programme. The ratio of male to female on the brain injury programme was 55:45. Despite the increasing number of women experiencing ABI, brain injury research has long been viewed through a masculine perspective (www.pinkconcussions.com). A scoping literature review carried out by this author revealed the lack of research on mothers with ABI compared to fathers. There is, however, an increasing focus on gender in epidemiological research, and the World Health Organization’s view that gender is a social determinant of health “must be considered by researchers to enable a deeper understanding of the individual experience” (O’Reilly et al. 2018: 2340). The experience of women with ABI can be further complicated when a woman is a mother. There is a dilemma for disabled mothers with them being seen simultaneously as givers and receivers of care. The societal expectation of the mother as the primary caregiver in the family (Hayes, 1996) is challenged by the societal view of people with disabilities requiring care. Feminist disability theory (Garland-Thomson, 2005) can be used to explore this dilemma and make a case for the value of interdependence between people with and without disabilities. While the hegemonic quality of ideal motherhood leads all mothers to feel a pressure to live up to the standards of the ‘perfect’ mother, mothers with disabilities face even more challenges as they can be viewed by society as being unable to perform motherhood adequately (Malacrida, 2009). As part of a PhD study, this challenge is being explored in an Irish context, by way of qualitative research with a sample of mothers with ABI. Using a participatory action research approach, research is being undertaken where mothers with a brain injury will have the opportunity to engage in research with a social work practitioner to explore their lived experience. Individual narrative interviews and a Co-Operative Inquiry group are the methods being used to gain insight into the lived experience of mothers with ABI and to work in collaboration with them in order to improve the quality of rehabilitation services for this client group. This research collaboration between social worker and service users aims to challenge hegemonic assumptions about mothers and about people with disabilities, and contribute to the provision of support services that have value and meaning for the individual and the wider societal system.
154 Final Analysis of the Double-Blind, Randomized, Surgical Sham-Controlled, Phase 2 Stemtra Trial: 1-Year Safety and Efficacy Outcomes in Patients With Chronic Motor Deficits Secondary to Traumatic Brain Injury
Alan H. Weintrauba, Steven C. Cramerb, Gary K. Steinbergc, Masahito Kawaborid, Santosh Kesarie, Hideaki Imaif, Leonid I. Groysmang, Takao Yasuharah, Anthony S. Kimi, Benjamin M. Frishbergj, Neil E. Schwartzk, Bijan Nejadnikl, Damien Batesl, Peter McAllisterm
aCraig Hospital, Rocky Mountain Regional Brain Injury System, Englewood, USA, bDepartment of Neurology, University of California, Los Angeles; and California Rehabilitation Institute, Los Angeles, USA, cDepartment of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, USA, dDepartment of Neurosurgery, Hokkaido University Hospital, Sapporo, Japan, eDepartment of Translational Neurosciences, Providence Saint John’s Health Center; Pacific Neuroscience Research Center, Santa Monica, USA, fJCHO Tokyo Shinjuku Medical Center, Tokyo, Japan, gUniversity of California, Irvine, Medical Center, Orange, USA, hDepartment of Neurological Surgery, Okayama University Graduate School of Medicine, Okayama University Hospital, Okayama, Japan, iUCSF Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, USA, jThe Neurology Center of Southern California, Carlsbad, USA, kDepartment of Neurology and Neurological Sciences, and Stanford Stroke Center, Stanford University School of Medicine and Stanford Health Care, Stanford, USA, lSanBio, Inc., Mountain View, USA, mNew England Institute for Neurology and Headache, Stamford, USA
ABSTRACT
Background: Currently, there are no approved pharmacological or biological agents available for the treatment of chronic motor deficits secondary to traumatic brain injury (TBI).
Objective: To determine if intracranial implantation of modified bone marrow-derived mesenchymal stromal cells (SB623) can improve chronic motor deficits secondary to TBI.
Methods: The Phase 2 STEMTRA trial (NCT02416492) is an international, 1-year, double-blind, randomized, surgical sham-controlled study which enrolled 63 patients with moderate to severe TBI (GOS-E scores: 3–6) who were ≥12 months post-injury with chronic motor deficits. Patients were randomized in a 1:1:1:1 ratio to single-dose stereotactic implantation of 2.5x106, 5.0x106, or 10 × 106 SB623 cells or surgical sham procedure. Safety and efficacy were assessed in 61 patients who underwent surgery (SB623: 46, Control: 15).
Results: The primary efficacy endpoint of statistically significant improvement of the Fugl-Meyer Motor Scale score (FMMS) from baseline compared to controls at 6 months was achieved (least squares mean [SE] SB623: +8.3 [1.4] 95%CI: 5.5, 11.2 vs. control: +2.3 [2.5] 95%CI: −2.7, 7.3, P = 0.04). SB623-treated patients experienced a more rapid improvement of FMMS than controls to 6 months, with sustained improvement to 12 months. The change of FMMS from baseline was not significantly different for SB623-treated vs. control patients at 12 months. However, patients treated with the SB623 5.0 × 106 cell dose (n = 15) experienced statistically significant improvement of FMMS from baseline compared to controls at 6 months (SB623 5 × 106 cell dose: +10.9 [1.8] 95%CI: 7.3, 14.6 vs. control: +2.4 [1.8] 95%CI: −1.2, 6.0, P = 0.002) and 12 months (SB623 5 × 106 cell dose: +10.5 [1.8] 95%CI: 6.7, 14.3 vs. control: +4.1 [1.8] 95%CI: 0.3, 7.9, P = 0.02). At 12 months, the secondary efficacy endpoint of Disability Rating Scale did not improve significantly from baseline for SB623-treated or control patients. Other secondary efficacy endpoints of Action Research Arm Test, NeuroQOL upper and lower extremity function T-scores, and Gait Velocity were statistically significantly improved from baseline for SB623-treated patients and were greater than controls, but differences between SB623-treated and control patients were not statistically significant. At 12 months, all SB623-treated and control patients had experienced at least one treatment-emergent adverse event with headache being most frequently reported. Treatment-emergent serious adverse events (TESAEs) were experienced by four (8.7%) SB623-treated (delirium x2, TIA, seizure x2, worsening of poor balance) and three (20%) control (wound infection, bicycle fall, seizure) patients (P = 0.35). The majority of TESAEs were not related to cell treatment. At 12 months, no patients had withdrawn due to adverse events, and there were no deaths or dose-limiting toxicities.
Conclusion: Implantation of SB623 cells appears to be safe and well tolerated. The primary efficacy endpoint of significant improvement of FMMS at 6 months was achieved, with improvement of function and activities of daily living at 12 months.
155 Outcomes related to post traumatic growth after acquired brain injury: a longitudinal analysis
Anna Igoea, Deirdre Twomeya, Niamh Allenb, Dr. Simone Cartonc, Professor Nuala Bradya, Fiadhnait O’Keeffed
aUniversity College Dublin, Dublin, Ireland, bTrinity College Dublin, Dublin, Ireland, cNational Rehabilitation Hospital, Dublin, Ireland, dSt. Vincents University Hospital, Dublin, Ireland
ABSTRACT
Post Traumatic Growth (PTG) is a form of positive psychological change that occurs for some individuals following traumatic experiences. High levels of PTG have been reported among survivors of acquired brain injury (ABI). Yet, if, how, or why PTG can occur remains unclear. We investigated PTG and factors pertaining to its development in people with moderate to severe ABIs. Thirty-two participants completed outcome measures at two time-points (1 year, and 8 years post-ABI). Outcome measures included the Hospital Anxiety and Depression Scale (HADS), the Brief-COPE, the World Health Organization Quality of Life measure (WHOQOL) and the European Brain Injury Questionnaire (EBIQ). The Post Traumatic Growth Inventory (PTGI) was included at the 8-year follow up timepoint. More than half of all participants (53.13%) reported moderate to high levels of PTG. Presence of PTG around eight years post-ABI was associated with fewer depressive symptoms (p < 0.05), fewer ongoing symptoms of brain injury (p < 0.05), and better quality of life (physical, p < 0.05; psychological, p < 0.001; environmental, p < 0.01). No significant associations were observed at the earlier time point. Results from multiple regression analyses revealed that one-year post-ABI, fewer symptoms of depression (p < 0.05), more symptoms of anxiety (p < 0.05), and use of adaptive coping (p < 0.05) were significant predictors of later PTG. At eight years post-ABI, fewer symptoms of depression (p < 0.05), fewer ongoing symptoms of brain injury (p < 0.05), better psychological quality of life (p < 0.01) and use of adaptive coping (p < 0.10) provided substantial contributions to variance explained in PTG at the same timepoint. These results suggest that long-term-use of adaptive coping strategies and psychological wellbeing may encourage PTG for people with ABIs. Evidently, factors that influence the presence of PTG may vary across time. These findings demonstrate the utility of long-term neuro-psychological support in promoting and maintaining positive long-term outcomes for those with ABIs. Improving access to these services may increase prevalence of PTG and other positive outcomes for those with ABIs.
156 Prolonged Disorders of Consciousness (pDOC) and the coma recovery scale- revised: the need for training and specific skillset
Fiona Haugheya, Alison McCanna, Professor Mark Delargya, Catriona Morana
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland
ABSTRACT
Introduction: Proficiency in the use of a range of behavioral assessment tools is essential to identify awareness in people with pDOC (RCP 2020). Assessment tools have been criticized for their lack of sensitivity (Schnakers, Casacolina.org; 2022). Along with potential challenges that may exist with the tools, limited training in the use of specialized tools may be as great a problem. Personal judgment often plays the key role in ‘diagnosis’ of awareness or unawareness (Wade 2016).3 Training to administer some specialist tools has been noted as a potential limitation-making use of the tool “prohibitive for clinicians” (Seel et al; 2010, p. 1805). Clinical guidelines advocate the need for training and mentorship (RCP 2020)1, however, there is sparce empirical evidence that training in the use of any of the tools makes a difference in the overall outcome of the assessment findings.
Aim: To prove that the results of the CRS-R (Giacino et al, 2004) will differ depending on the level of training and experience of the assessor in the assessment of consciousness.
Method: Assent was obtained from emergency contacts of six participants with pDOC. ‘Untrained Assessors’ were sampled following an e-mail invitation to clinicians with no formal training in the assessment of pDOC. ‘Trained Assessors’ are ‘Expert’s in the use of the Sensory Modality Assessment and Rehabilitation Technique (SMART) (Gill Thwaites & Munday 1999;2004). Four consecutive assessments were carried out by trained assessors, four by the untrained assessor; within a 24 hour period and within standardized clinical conditions. The findings of each assessment were kept ‘blinded’ between assessors. Untrained assessors completed a questionnaire documenting their understanding of pDOC following the four assessments. Descriptive analysis was used for this small sample size.
Results: Six patients were assessed. 50% of the untrained assessors were unable to provide a diagnosis using the CRS-R-“I don’t know.” One untrained assessor’s findings corroborated with the trained assessor- a patient who demonstrated “Emerged” awareness. One untrained assessor was unable to diagnose the patient and attributed three potential levels of awareness- “vegetative state, minimally conscious state (MCS) or locked in syndrome.” Despite four of the patients being categorized with MCS, and this being confirmed by other assessments such as the SMART, behaviors associated with MCS could not be definitively identified by untrained assessors. Visual skills proved most challenging to interpret. Untrained assessors (n = 4) reported that training using a DVD was not sufficient to address the complexity of this group.
Conclusion: This small study illustrates the role for education, training and mentorship for clinicians assessing and treating patients with pDOC. It highlights the risks associated with lack of mandatory training in the use of specialist tools, including misinterpretation of behaviors and subsequent potential misdiagnosis of levels of consciousness.
157 Positive behavior support for adults with acquired brain injury and challenging behavior: a randomized controlled trial
Jennie Ponsforda,b, Amelia Hicksa,b, Kate Goulda,b, Malcolm Hopwoodc, Dr. Marina Downinga,b, Tim Feeneyd
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia, cDepartment of Psychiatry, University of Melbourne, Parkville, Australia, dBelvedere Health Services and the Mill School, Essex Junction, USA
ABSTRACT
Challenging behaviors are common and disabling consequences of acquired brain injury (ABI), causing stress for close others and disrupting community integration. Positive Behavior Support interventions have support from case studies as a means of reducing these behaviors, but controlled trials are lacking. This study aimed to evaluate, in a randomized waitlist-controlled trial, the efficacy of a Positive Behavior Support intervention, termed PBS+PLUS, in reducing challenging behaviors after ABI. Participants included 49 individuals with ABI and their close others. The design was a randomized waitlist-controlled trial with 12-month follow-up. The 12-month intervention involved setting collaborative goals toward a more meaningful life with the individual with ABI, and identifying and addressing barriers to achieving these, including challenging behaviors, through training, environmental supports or restructuring involving clients and close others. The primary outcome measure was the Overt Behavior Scale (OBS). The Challenging Behavior Self-Efficacy Scale (CBSES) was a secondary outcome, assessing Close-Others’ self-efficacy in managing challenging behavior. Data analyses involved mixed effects and negative binomial regressions examining change over time by group. On the OBS, the PBS+PLUS Intervention group showed a significant reduction in challenging behavior over the 12-month intervention. However, the Waitlist Treatment as Usual group showed a similar degree of improvement on the OBS over the 12-month waitlist period. The Waitlist Treatment as Usual group was receiving intervention from other providers during this period. Gains continued for 8 months post-intervention and remained below baseline at 12 months. The PBS+PLUS intervention resulted in significantly greater gains in Close Others’ confidence in managing challenging behaviors on the CBSES, relative to the Waitlist group which showed no such gains. In conclusion, whilst we cannot say this intervention is more effective than any other, the study did show that PBS+PLUS can result in significant and sustained reductions in challenging behavior in individuals with severe ABI, and increase confidence of close others in managing difficult behaviors.
158 Kinetic reading, a prosthetic effect on reading in subjects with left unilateral spatial neglect?
Agnès Weill-Chounlamountrya,b, Flora Benvegnua,b, Charlotte Dehollaina,b, Anaïs Migeota,b, Blandine Pescia,b, Eléonore Bayena,b, Pascale Pradat-Diehlb, Marie Villaina,b
aService de Médecine Physique et de Réadaptation - AP-HP - Hôpital De La Pitié-Salpêtrière, Paris, France, bSorbonne Université, GRC n°24, Handicap Moteur et Cognitif & Réadaptation (HaMCRe) AP-HP. Sorbonne Université, Paris, France
Unilateral spatial neglect (USN) is a disorder of spatial cognition or attention that affects perception, memory, motor planning and executive functions. Spatial difficulties occur in the opposite field to that of the cerebral lesion with a more common frequency and severity for left USN than right USN. While many studies have focused on the management of visuo-spatial difficulties in terms of spatial exploration or prosthetics (Azouvi et al., 2017), few focus on reading abilities in subjects with left NSU and yet reading text is often impaired. Reading French involves rightward saccades and leftward retro saccades to return to the line and training to produce voluntary saccades to the neglected side in left NSU subjects provides limited improvement (Szalados et al., 2021), whereas smooth pursuit training appears to be more interesting (Kerkhoff et al., 2012). The aim of this preliminary study was to determine whether kinetic reading could improve text-reading performance as opposed to traditional reading. A single case experimental design ABAB (introduction/withdrawal) experimental study was conducted with randomization of each phase (phase A = simple reading; phase B = kinetic reading) in two patients with severe left USN after unilateral right-hemisphere stroke: the first at seven months post onset (P1) and the second at seven weeks post onset (P2). Effect size was measured on the outcome measures of the number of words read per minute and the number of errors made in one minute. The results showed that the number of words that were read was higher in the kinetic reading condition in both participants (d = 1.73, p = 0.02; P1 showed a stronger effect (d = 1.99, g = 1.67) than patient 2 (d = 1.46, g = 1.32)) and that the number of errors decreased particularly in the kinetic condition also in both participants (d = −2.24, p = 0.006; P1 showed a more moderate effect (d = −2.22, g = 1.87) than P2 (d = −2.27, g = −2.05). Kinetic reading appears to have a prosthetic effect in left USN subjects and may help to improve the functional goal of reading.
160 Smiling and laughing in patients with Prolonged Disorder of Consciousness (PDOC) following hypoxic brain injury- a case series review
Catriona Morana, Alison McCanna
aNational Rehabilitation Hospital, Dublin, Dun Laoghaire, Ireland
ABSTRACT
Introduction: The phenomenon of laughing and smiling in PDOC patients is poorly defined in the literature. The presentation of these behaviors can cause confusion for clinicians and families as it has been acknowledged in eminent guidelines (Royal College of Physicians, 2020) that both smiling and laughing may be reflexive features of vegetative state.
Aim: This case series review explores the trend in presentation of smiling and laughing in five patients with PDOC following hypoxic brain injury, many months since the onset of their injury. The types of stimuli, if any, which may have evoked these responses was explored. Details regarding the nature and extent of the injury sustained and the presentation of laughing/smiling responses was illustrated.
Method: Purposive sampling identified a suitable case series to be included in an audit of the clinical records. A data gathering tool was designed by the authors and reviewed by interdisciplinary expert colleagues to ensure face validity. It gathered key data points relating to the person’s etiology, imaging, assessments of awareness completed and their clinical presentation.
Results: All 5 patients (3 males and 2 females) presented in vegetative states post Out of Hospital Cardiac Arrest. Time from onset to admission to the post-acute rehabilitation ranged from 339 to 1815 days. The age range of participants was between 22 and 66 years. All 5 had comprehensive interdisciplinary team assessment completed using tools including the Wessex Head Injury Matrix (Shiel et al., 2000), the Coma Recovery Scale Revised (Giacino et al., 2004), the Sensory Modality Assessment and Rehabilitation Technique (SMART; Gill-Thwaites & Munday, 2004), the Music Therapy Assessment Tool for Awareness in Disorders of Consciousness (MATADOC; Magee et al., 2014) and a local unstandardized Speech and Language therapy screening tool. The behaviors of laughing and smiling were observed in this patient cohort and were characterized as non-meaningful responses, reflexive or spontaneous in nature. The primary triggers to the behaviors of laughing and smiling amongst this small cohort of 5 patients include olfactory stimuli (n = 1) and loud sounds in the environment (n = 5).
Conclusions: This case review identified an occurrence of behaviors of laughing/smiling in a purposive sample of 5 patients presenting with PDOC following an etiology of hypoxic brain injury. The presentation of laughing/smiling in the PDOC population is identified as having potential to lead to misdiagnosis (Royal College of Physicians, 2020), and this review emphasizes the importance of comprehensive interdisciplinary assessment by teams with experience in PDOC to support family and carer interpretation of these behaviors and patient diagnosis.
161 Addressing the financial empowerment needs of adults living with acquired brain injury through a co-design focus-group study
Lisa Engela,b, Roheema Ewesesana, Ibiyemi Arowoloa, Kafayat Adedotuna, Fred Dugdalec
aThe University Of Manitoba, Winnipeg, Canada, bThe Institute for Work & Health, Toronto, Canada, cThe Manitoba Brain Injury Association, Winnipeg, Canada
ABSTRACT
Introduction: Approximately 30% of acquired brain injury (ABI) survivors experience challenges with managing their finances and financial well-being. Despite this, little is known about financial empowerment programs to improve the financial experiences of adults living with ABI.
Objective: To generate program ideas from the perspectives of adults with ABI lived experience and expertise for developing innovative financial empowerment programs sensitive to the needs of adult ABI-survivors.
Methods: This descriptive qualitative co-design focus-group study included seven focus-groups: ABI-survivors (n = 5 groups), caregivers/family (n = 1 group), and Project Advisory Group (n = 1 group). The included participants were all adults (18+ years). The 15 ABI-survivor participants were from Manitoba (Canada) and had slightly more self-identified women (66.7%) and varied ABI histories (i.e., experienced traumatic brain injury (60%), stroke (13.3%), or other ABI-mechanisms (26.7%); had lived with ABI for at least 1-year (6.7%) or more than 15 years (33.3%)). The two family participants were both female, living in Manitoba, and caregivers of adults living with ABI. The Project Advisory Group included eight individuals which were 75% self-identified women and included Canadian researchers, local brain injury association staff, and one ABI-survivor. All focus-group discussions were completed between January and May 2022, audio-recorded, and guided by questions about financial empowerment challenge areas for adults living with ABI. Researchers used an iterative and inductive coding process guided by content analysis and framework approach.
Results: Seven idea categories, including 27 different ideas, emerged. They included combinations of 1) human-interaction dependent services, 2) informational products, and 3) institutional or governmental advocacy. All focus-groups discussed the service idea of a trusted financial coach that is knowledgeable about ABI and financial issues as crucial to improving financial empowerment for adults living with ABI. Other service needs include ABI-knowledgeable interactive financial helpline and access to free or low-cost legal and counseling services. Product ideas include educational or informational resources (e.g., handbook, pamphlet), flowcharts, informative videos or podcasts, and a reminder wallet-card for adults living with ABI. Participants also emphasized advocacy to improve accessibility to financial resources, financial protection and safety, public and government awareness about living with ABI, and increased ABI care funding related to decrease cost of longitudinal ABI care. Other ideas intersected advocacy, service, or product categories such as providing training as well as improved access to physicians knowledgeable about completing financial-related medical forms and ABI.
Conclusions: The idea categories identified provide a framework for developing innovative programs tailored to meet the financial empowerment needs of adults living with ABI. This is important as addressing financial and economic challenges is foundational to addressing the long-term health and wellness of adults living with brain injury.
Funding: This study was funded in part by the Government of Canada’s Social Development Partnerships Program (Disability component).
162 A photovoice study demonstrates that acquired brain injury amplifies personal financial capability challenges and creates barriers to financial well-being
Lisa Engela,b, Ibiyemi Arowoloa, Roheema Ewesesana, Mohammad Khana, Jacquie Ripata, Carolina Bottaric,d, Anne Hunte, Frederique Poncetd,f, Jane Karpag
aThe University Of Manitoba, Winnipeg, Canada, bThe Institute for Work & Health, Toronto, Canada, cUniversite de Montreal, Montreal, Canada, dCentre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, Montreal, Canada, eUniversity of Toronto, Toronto, Canada, fLethbridge-Layton-Mackay Rehabilitation Center, Montreal, Canada, gBrandon University (Winnipeg Campus), Winnipeg, Canada
ABSTRACT
Individuals who live with acquired brain injury (ABI) experience increased challenges with financial capability (i.e., financial-related knowledge, skills, and behaviors), which can lead to reductions in financial well-being (i.e., subjective or objective financial outcomes) and negatively influence community participation and health. However, there is a dearth of research exploring the lived financial-related experiences of adults living with ABI, information which could help develop valid and effective ways to address ABI-survivors’ financial well-being, ABI recovery, and health. The aims of this research were to understand the financial-related experiences of adults living with ABI and to identify facilitators and barriers to their financial capability and financial well-being. Researchers conducted a PhotoVoice study between December 2020 and December 2021. Over 3–5 weeks participants took photos of their financial capability and financial well-being experiences and were interviewed about their photos’ meaning and context. Researchers thematically analyzed interview transcripts using an iterative inductive framework approach, including triangulation and member checking to address study rigor. Researchers recruited 17 adults who live with ABI from urban and rural parts of the Canadian province of Manitoba. Maximum variation sampling included participants across demographic characteristics that could influence results (i.e., age, gender, and technology access and use). Ten participants completed the study online and seven completed the study in-person. Participants were between 31 to 82 years old, sustained their ABI between the years 1979 and 2018, and were 41% women. Participants’ household incomes tended to be low (range: <$20,000 – <$55,000 CAD). Three main themes arose from the data. First, chronic ABI-related sensory, physical, mental, and cognitive changes often negatively influenced financial capability, increased the complexity of managing finances, and were a barrier achieving financial well-being. Often this further negatively influenced mental health. For example, cognitive challenges with understanding, decision making, forgetting, or disorganization prohibited completing financial activities and increased frustration. Second, financial knowledge, while important in many situations, was not enough to independently promote financial capability for many ABI-survivors. Third, finding a good fit for the individuals’ financial capability, their personality characteristics such as openness or resourcefulness, financial values, and their personal context was pivotal to financial-related participation and performance. Part of finding a good fit was the need to find strategies for financial capability enhancement that work for each individual and in their own context. Comprehensively addressing financial capability and financial well-being should be pivotal parts of ABI rehabilitation as ABI-survivors report increased financial-related challenges that influence many other life areas and living with ABI. This study supports growing evidence for using a comprehensive and individualized approach to addressing the financial experiences of those living with ABI, which extends beyond a focus on knowledge and skills only to also address the person in their specific context.
163 Developing and sustaining a brain injury patient registry for conducing large-scale basic and translational research
Melissa Duffa, Emily Morrowa, Malcolm Edwardsb, Ryan McCurdya, Sharice Clougha, Nirav Patela, Kimberly Walsha, Natalie Covingtonc
aVanderbilt University Medical Center, Nashville, USA, bWilliam and Mary College School of Law, Williamsburg, USA, cUniversity of Minnesota, Minneapolis, USA
ABSTRACT
Interindividual heterogeneity among individuals with traumatic brain injury (TBI) is a long-recognized obstacle to significant breakthroughs in basic and clinical research. The challenge of heterogeneity is often exacerbated by inconsistent participant recruitment strategies and commonly used group study designs with small or poorly characterized samples. These designs do not support analyses that capture factors contributing to interindividual variability in presentation, long-term outcome, and response to treatment. In the field of cognitive neuroscience, patient registries designed to provide access to large numbers of well-characterized research participants have been highly successful in advancing basic science and cognitive rehabilitation research on the effects of brain damage to various cognitive and behavioral outcomes. We propose that patient registries have unique utility in advancing our understanding of individual differences and improving functional outcomes in brain injury research and care. Patient registries are replicable across research and clinical sites. In contrast to some national registries, regional registries with a rehabilitation focus can also support community-based research and personalized treatment designs in the specific communities in which individuals with brain injury live and work. Here, we report on the process of developing and sustaining the Vanderbilt Brain Injury Patient Registry. The long-term goal of the Registry is to capture, characterize, and predict individual differences in deficit profile and outcomes to better personalize treatment. We collect demographic, neuropsychological, and neuroanatomical data and information regarding community integration. We supplement our core neuropsychological battery with experimental measures we have been refining to have increased sensitivity to the detection of memory impairment and hippocampal dysfunction, which is a specific focus of our lab. We use a range of community-based methods and social media ads to recruit a diverse participant pool. We have recruited 174 individuals with TBI, and long-term retention is high. Recruiting a racially and ethnically diverse sample has been challenging and remains an area of increased focus. To address accessibility barriers in participation, we provide compensation for travel, have a range of tasks that can be completed online reducing the need to physically come to the lab, and implement a laptop loan program that allows for remote data collection for individuals without a personal computer. Developing and sustaining a patient registry is feasible. The infrastructure provided by a patient registry offers a methodological tool and resource for improving our understanding of interindividual differences in behavioral profiles and functional outcomes, as well as the development of interventions to improve long-term outcomes. The registry approach allows frequent and sustained interactions over time with individuals with TBI. This allows participants, who are the critical stakeholders in our research, to directly inform the direction of the research program and be at the center of the effort to improve long-term outcomes following brain injury.
164 A youth empowerment programme for children and families living with acquired brain injury
Mary-Elaine McCaverta, Meg Irwina, Paula Mathersa, Donna O’Donnellb
aBrain Injury Matters, Belfast, United Kingdom, bAcquired Brain Injury Rehabilitation Team, Southern Health and Social Care Trust, Portadown, United Kingdom
ABSTRACT
Background: Acquired Brain Injury (ABI) in childhood can result in losses and alterations in social, cognitive, physical, and emotional functioning. Together, these impact academic performance, social activities, and family life (Anderson et al., 2006). Based on a secondary prevention model in which young people with and ABI and their families become an “expert family” in relation to the knowledge and skills required to live with their injury, (Beth-Halachmy et al., 2015), Brain Injury Matters NI developed the Youth Empowerment Programme (YEP) in 2020.
Methods: The programme was co-created with young people aged 13 to 18 years, with an ABI, resident in Northern Ireland (NI). The YEP involves three elements: 1) one-to-one family intervention and support, 2) activities and events, and 3) the mentoring programme (which can only be accessed by those in the Southern Trust area, one of five NI healthcare trusts). Engagement with the programme lasts up to a maximum of one year, and aims to facilitate: a) psychological adjustment, social interaction, educational engagement, and independence with activities of daily living for the young person and b) understanding of ABI and its meaning for all family members, including, siblings and parents. Brain Injury Matters NI (BIM), in partnership with a local university (Queen’s University Belfast), evaluated the YEP via standardized self-report measures completed throughout the programme (Personal Evaluation Inventory (Shrauger, 1990); the Children’s Perceived Self-Efficacy Scale (Bandura, 1990); Self-Esteem Scale (Rosenberg, 1979); Pediatric Quality of Life Inventory (Varni et al., 1999) and qualitative interview data collected with family members upon discharge via service-specific questionnaires.
Results: Since the YEP commenced in 2020, the programme has met referral targets of 10 referrals per year. Significantly, with regards to the individual elements of the programme: 1) one-to-one family intervention and support was accessed by 37 young people and their families 2) activities and events were attended by 152 people including young people with ABI, siblings, parents, and carers (these events were planned and delivered by four young service users) and 3) the mentoring programme was co-produced by four mentees and 2 mentors. All YEP elements were supported by Brain Injury Matters’ staff.
Conclusions: The YEP programme shows promise in addressing unmet needs within service provision in NI. The self-management approach, facilitated by this program, provides a more stable, longer-term base for the young person with ABI and their family to adapt to the injury’s impacts, gain a sense of mastery over their own family’s experiences and live their best possible lives.
165 Mentoring for children and young people with acquired brain injury: preliminary outcomes from a pilot programme
Mary-Elaine McCaverta, Paula Mathersa, Meg Irwina, Donna O’Donnellb
aBrain Injury Matters, Belfast, United Kingdom, bAcquired Brain Injury Rehabilitation Team, Southern Health and Social Care Trust, Portadown, United Kingdom
ABSTRACT
Background: Acquired Brain Injury (ABI) in childhood has been associated with long-term cognitive, behavioral, and psychosocial challenges, which subsequently impact quality of life, school, and family functioning (Spina et al., 2005). Additionally, late effects of ABI can emerge as the injured brain fails to develop optimally. Together, these can lead to social exclusion and emotional dysregulation (Doherty & McCusker, 2005; Soo et al., 2014). To address these psychosocial difficulties for children with ABI resident in Northern Ireland (NI), a pilot peer mentoring programme was developed by Brain Injury Matters NI, in 2021. This programme was created in partnership with the Southern Health and Social Care Trust (SHSCT), with the aim of empowering young people with an ABI to a) integrate and socialize within their local community, and b) articulate their needs to peers, their support network and community, so that their ABI, and its impacts, could be better understood. Four mentees (young people with an ABI, resident in the local area, with a mean age of 14), two mentors (young adults with ABI, resident within the SEHSCT, aged 18–30 years) and a facilitator from Brain Injury Matters (BIM) co-produced the programme.
Methods: Following participation in 11 in-person mentoring sessions, mentees were invited to participate in semi-structured interviews. Data were collected utilizing a study-specific questionnaire, as part of a wider service evaluation into BIM child and youth services.
Results: Interviews highlighted that the pilot mentoring programme allowed the young people with ABI to: 1) Feel empowered to live life following their injury: “I just liked having someone to talk to, someone … that understands about like the brain injury … and someone has been able to fully explain to me what I can really do, and ways I can really do it in a different way, you know?” 2) Discuss their ABI and its impact on their life: “I really do feel more happier, about explaining to people and talking with people about it now. I’m not scared or embarrassed or anything” and 3) Increase their community participation and social networks; “it’s the only thing that I do that’s out of our house … just being able to talk with the group, practicing speaking to other [mentees and mentors] and just getting used to doing that, it makes it easier over time.”
Conclusions: All mentees interviewed stated that they benefited from the mentoring programme. As such, this programme holds promise as a cost- effective and inclusive approach to addressing social exclusion and related psychosocial dysregulation for young people living with an ABI in NI. Trialing this programme within other NI health trusts is recommended as this will determine the feasibility and acceptability of a NI-wide programme.
166 Cognitive demands of computer-mediated communication: a scoping review
Catherine Bosyja, Sukhman Baatha, Bilge Mutlub, Melissa Duffc, Lyn Turkstraa
aMcmaster University, Hamilton, Canada, bUniversity of Wisconsin-Madison, Madison, USA, cVanderbilt University, Nashville, USA
ABSTRACT
Computer-mediated communication (CMC) is ubiquitous in today’s world and can play an important role in building and maintaining social connections. CMC may be of particular benefit to individuals with TBI, allowing access to information and providing wide opportunities for social connections. The cognitive demands of CMC use, however, could limit its utility for this population. CMC routinely requires the use of high-level executive and other cognitive functions that are often impaired in adults with TBI. As a result, adults with TBI may struggle with these CMC demands, leading to challenges such as cognitive overload, confusion, and fatigue, inhibiting young adults with cognitive impairments from reaping the same CMC-related benefits as typical adults. As a first step in identifying supports for adults with TBI, we conducted a scoping review of the literature to summarize evidence of cognitive demands accompanying CMC use. Of 5955 studies initially identified, 78 met criteria for full-text review, with a final sample of 15 papers. Results highlighted inconsistencies across social media platforms in demands on memory and executive functions. Relationships between CMC use and cognitive functions were mixed, with some evidence suggesting patients with better cognitive function used CMC more and others showing the opposite effect. Based on the results and learning theories in adults, we created a list of considerations and subsequent design implications for software developers to use when developing CMC platforms. Broadly, design implications fell into two main categories: 1) features to improve retention of information learned through CMC, and 2) features to reducing the cognitive burden of navigating CMC platforms and processing information. In the first category, we suggest that designers embed reminders of identity-relevant and autobiographical information into CMC platforms; slow down the process of online communication to orients users’ attention toward CMC information; and ensure posts and information stand alone as a complete, contained ideas. To reduce the cognitive burden of CMC usage, designers should consider creating features that filter out negative CMC content while reframing the remaining content positively; minimize unnecessary distractions and interruptions to CMC; link related posts to aid in information integration; remove or minimize duplicate posts to minimize need for novelty judgments; and use accessible bookmarks to aid in later information processing and sourcing. We also propose that designers aim to support executive functions by increasing emphasis on social support. Together, these considerations and design implications will help make online spaces more accessible to individuals with TBI.
167 Examining the factors that influence attention performance following concussion
Kaitlyn Butterfielda, Samantha Robertsa, Danielle DuPlessisa, George Mochizukib, Magdalena Wojtowicza
aDepartment of Psychology, York University, Toronto, Canada, bSchool of Kinesiology and Health Science, York University, Toronto, Canada
ABSTRACT
Objective: Attention has been implicated as a risk factor for concussion (i.e., increased injury prevalence among athletes with attention-deficit/hyperactivity disorder; ADHD) and as a potential deficit following injury. The current study examined differences among athletes across three sub-domains of attention according to concussion history, as well as examined individual (e.g., sex, sport participation), cognitive, and balance-related factors that may predict reaction time performance.
Methods: 234 varsity athletes across 12 sports participated in pre-season testing from June 2019 to January 2020. Measures included the Sport Concussion Assessment Tool (SCAT-5), force plate balance data, and the Attention Network Task Integrated (ANT-I). The main outcome measure was reaction time (RT) from the ANT-I. Athletes were divided into groups based on concussion history (no history of concussion [n = 127] and history of concussion [n = 93]), as well as sport contact type (collision [n = 72], contact [n = 80], and limited/no contact [n = 68]). A repeated measures ANOVA was conducted to examine ANT-I performance differences based on concussion history. A stepwise regression was conducted to examine whether performance can be explained by additional factors including concussion history, biological sex at birth, sport contact type, SCAT-5, and force plate balance data.
Results: Athletes with a history of concussion had significantly slower reaction time on the ANT-I (M = 627.09 ms, SD = 78.71) than those without (M = 601.58 ms, SD = 70.19; p = 0.012; d = 0.345). There were significant interactions between history of concussion and performance on alerting (p = 0.0311, ηp2 = 0.021) and orienting conditions (p = 0.009, ηp2 = 0.022), such that those with a history of concussion were slower when alerting tones, valid orienting cues, and no cues were presented. Number of concussions and time since injury were not related to performance. Regression findings indicated slower RT was primarily predicted by having lower scores on the Standardized Assessment of Concussion (SAC) from the SCAT-5, participation in a collision-type sport, and having a history of concussion, F(3,188) = 8.953, p < 0.001, accounting for 12.5% of the total variance in RT (R2 = 0.125, Adjusted R2 = 0.111), with each accounting for 6.3%, 2.4%, and 1.5% of the variance in RT, respectively. Force plate measures were not significant predictors in RT performance when added to the model.
Conclusion: Athletes with a history of concussion performed significantly slower on an attention task with challenges in alerting and orienting networks. In addition to concussion history, an athlete’s score on the SAC and participation in a collision-type sport emerged as significant predictors of attention performance. Future studies should adopt a longitudinal approach to understand whether these cognitive and balance-related factors precede injury or manifest post-concussion.
168 “The fifteen year studies” longitudinal examination of military traumatic brain injury: year 11 report to the United States congress
Louis Frencha,b,g, Tracey A Brickella,b,c,g, Sara Lippaa, Risa Richardsond,f, Rael Langea,c,e,g
aWalter Reed National Military Medical Center, Bethesda, USA, bUniformed Services University of the Health Sciences, Bethesda, USA, cGeneral Dynamics Information Technology, Silver Spring, USA, dJames A. Haley Veterans Hospital, Tampa, USA, eUniversity of British Columbia, Vancouver, Canada, fUniversity of South Florida, Tampa, USA, gTraumatic Brain Injury Center of Excellence, Silver Spring, USA
ABSTRACT
In 2007 the Congress of the United States (US) mandated that the US military conduct a study for a 15 year period on the long term effects of traumatic brain injury incurred during the era of the wars in Iraq and Afghanistan (OIF/OEF). The law required that the study address: 1) The long-term physical and mental health effects of TBIs incurred by members of the Armed Forces during service in OIF/OEF; 2) The health care, mental health care, and rehabilitation needs of such members for such injuries after the completion of inpatient treatment through the Department of Defense, the Department of Veterans Affairs, or both; 3) The type and availability of long-term care rehabilitation programs and services within and outside the Department of Defense and the Department of Veterans Affairs for such members for such injuries, including community-based programs and services and in-home programs and services, and; 4) The effect on family members of a member incurring such an injury. A portfolio of three broad based studies was organized to address these elements. The first included subjects from across the spectrum of TBI severity and included both injured and non-injured controls assessed with neuroimaging, blood draws for genomic and proteomic analysis, sensory and cognitive examinations, and a variety of standardized outcome measures (i.e., Natural History Study). The second included the assessment of family caregivers and the impact on the health and quality of life of the families (i.e., Caregiver and Family Member Study). The third examined individuals that had transitioned from the military and entered the Veterans Administration Health system, including their ongoing health and rehabilitation needs (i.e., IMAP Study). The law mandated that periodic reports on findings be presented to Congress. This presentation focuses on data presented in our Year 11 Report to Congress and provides an overview of the information that has been published in over 150 peer-reviewed publications since the start of the study and includes the results of over 3500 comprehensive TBI and control evaluations and over 2400 family caregiver evaluations. Data on the effects of such an injury on the family unit will be given special emphasis as will information on long-term outcomes and those factors that contribute to both good and poor recovery.
Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency.
169 Elevated serum tau and UHCL-1 within the first 12-months post-injury are associated with worse anger, anxiety, depression, and cognitive complaints in the chronic phase of recovery following traumatic brain injury: a longitudinal study
Louis Frencha,c,e, Jessica Gillb, Sara A Lippaa, Samantha Baschensisa,c,d, Kelly C Gillowa,c,d, Alicia A Rogersa,c,d, Kendal E Cristaudoa,c,d, Lars Hungerfordc,d,h, Thomas Walkera,c,d, Jan Kennedyb,d,g, Tracey A Brickella,c,d,e, Rael T Langea,c,d,f
aWalter Reed National Military Medical Center, Bethesda, USA, bJohns Hopkins University, Baltimore, USA, cTraumatic Brain Injury Center of Excellence, Silver Spring, USA, dGeneral Dynamics Information Technology, Silver Spring, USA, eUniformed Services University of the Health Sciences, Bethesda, USA, fUniversity of British Columbia, Vancouver, Canada, gSan Antonio Military Medical Center, San Antonio, USA, hNaval Medical Center San Diego, San Diego, USA
ABSTRACT
Introduction: The purpose of this study was to determine whether blood-based biomarkers within the first 12 months of traumatic brain injury (TBI) can predict neurobehavioral outcome several years post-injury.
Method: Participants were 161 United States service members and veterans (SMVs) prospectively enrolled in the DVBIC-TBICoE 15-Year Longitudinal TBI Study, classified into two broad groups: (a) TBI group [n = 83; including uncomplicated mild, complicated mild, moderate, severe, and penetrating TBI, and (b) Control group [n = 78; including injured controls, and non-injured controls). For some analyses, the TBI group was divided into two severity groups: uncomplicated mild TBI (MTBI group); and complicated, moderate, severe, penetrating TBI combined (STBI group). Participants completed six select scales from the TBI-QOL within 12 months (baseline) and at 2-or-more years (follow-up) post-injury. Using blood collected at baseline, serum concentrations of Tau, NFL, GFAP, and UCHL-1 were measured using SIMOA™ technology.
Results: At baseline, elevated tau concentrations were predictive of worse depression (R2 = 0.111) in the entire TBI group, and in the MTBI group separately (R2 = 0.125; but not the STBI group). NFL was predictive of worse Cognitive Concerns (R2∆ = 0.126) in the MTBI group; and UCHL-1 predictive of worse Headaches, Anxiety, Depression, and Fatigue in the STBI group (R2∆ = 0.136–0.200). At follow-up, baseline tau was predictive of worse Anger, Anxiety, and Depression (R2 = 0.098 to 0.167) in the entire TBI group. Nonetheless, tau was a stronger predictor of Anger and Depression in the STBI group (R2 = 0.101–0.113; MTBI group: R2 < 0.076), and a stronger predictor of Anxiety in the MTBI (R2 = 0.210; STBI group: R2 = 0.127). In addition, baseline UCHL-1 was predictive of worse Depression (R2∆ = 0.107) in the entire TBI group, and in both MTBI (R2∆ = 0.207) and STBI (R2∆ = 0.159) groups separately. UCHL-1 was also predictive of worse Anxiety in the MTBI (R2∆ = 0.143) and STBI (R2∆ = 0.156) groups; and Cognitive Concerns in the MTBI group (R2∆ = 0.223). In the Control group, there were no meaningful associations between baseline biomarker concentrations and TBI-QOL scores at baseline or follow-up.
Conclusion: Serum Tau and UHCL-1 concentrations measured within the first 12 months following TBI of all severities was predictive of worse anger, anxiety, depression, and cognitive concerns 2-or-more years post-injury. There is a growing body of evidence to suggest that a blood-based panel including these biomarkers could be a useful tool for identifying individuals at risk of poor future outcome following TBI.
Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency.
170 Implementation of a standardized approach for assessment of the disorders of consciousness population in an inpatient brain injury rehabilitation setting
Kaitlin Haysa, Megan Butza, Kara Shidolfskya
aCraig Hospital, Englewood, USA
ABSTRACT
Craig Hospital, a spinal cord and brain injury inpatient rehabilitation facility in Colorado, admits individuals in the Disorders of Consciousness (DoC) population to inpatient, outpatient, and wellness center programs. Prior to 2012, the hospital did not have a standardized method for tracking changes in this population. Some clinicians used established measures such as the Western Neuro Sensory Stimulation Profile; however, disadvantages with this methodology included inconsistency in reporting scores in the medical record, unreliable administration of assessment batteries, and varying levels of comfort with assessment. An interdisciplinary task force created in 2012 evaluated 13 outcome measures used to assess the DoC population. After extensive discussion and review of available literature, Craig Hospital opted for the Coma Recovery Scale-Revised (CRS-R) as the standard assessment tool for the DoC population. Over the past decade, various approaches have been trialed to integrate the CRS-R assessment into the plan of care for this population; however, trialed methods presented challenges that were not sustainable. Beginning in 2021, six therapists representing all disciplines (i.e., Occupational, Physical, and Speech Therapies), along with a neuropsychologist were specially trained to administer the CRS-R. The established training model has been beneficial to foster accuracy in test administration and score interpretation, and is a feasible way to maintain the program despite the presentation of ongoing challenges. This training has included a formal curriculum using videos, real time observation, and performance of the assessment with oversight from a trained administrator to improve consistency in scoring. Since June of 2021, the team has performed 132 assessments on 15 patients. With the support of data from this period the team has shown an increase in inter-rater reliability, growth in appropriate referrals, and improved collaborative clinical understanding of varied patient presentations. Additionally, a formalized referral and documentation process has led to improved facility-wide support of ongoing initiatives. The committee has provided in-hospital education about DoC, possible interventions for this population, and CRS-R assessment. As the team continues to expand in scope, future areas of growth and perceived strengths and weakness of the program have been explored via the Clinical Sustainability Assessment Tool (CSAT). This tool is a subjective survey to project likelihood of ongoing sustainability of a program. Members of the CRS-R team completed this assessment individually, and the average overall sustainability score was 5.1/7. These results highlighted “Engaged Stakeholders” and “Organizational Readiness” as two domains with lower average sustainability scores. This tool will be used for future evaluation and identification of ongoing areas for programmatic development. The process used by Craig Hospital to develop and maintain this program may serve as a helpful template for other centers looking to develop a similar method of standardized assessment for the DoC population.
171 Changes in serum neurofilament light and brain white matter microstructure in female tackle football players: a pilot study
Donna Duffya, Emily Bechkea, Samantha Goldensteina, Samantha DuBoisa, Christopher Rheaa, Derek Monroea
aUNC Greensboro, Greensboro, USA
ABSTRACT
Repeated mechanical loading of the head can cause axonal damage in a dose-dependent manner. The corpus callosum (CC), a thick commissural white matter tract, is believed to be particularly sensitive to this loading. Neurofilament light (NfL) has emerged as a blood-based biomarker that is sensitive to axonal damage and may be useful for monitoring athlete brain health. However, the source of circulating NfL in contact and collision sport athletes who may have sustained axonal damage due to mechanical loading of the head, but have not been diagnosed with a brain injury, is poorly understood.
Purpose: To compare changes in serum NfL to changes in corpus callosum (CC) microstructure over a single season of competition.
Methods: semiprofessional female tackle football players (n = 5) had blood drawn (8.5 mL) and underwent diffusion MRI (64 directions, bval = 1300 s/mm2) and structural MRI (T1w, MPRAGE) before and after their season (4 games and 39 practices over 12 weeks). Despite that no participant reported a medical diagnosis of concussion during the season, participants were asked to report the presence and degree of concussion-related symptoms at each time point using the Rivermead Post-Concussion Questionnaire. Serum samples were assayed for (NfL) at pre and post season time points. The CC was reconstructed for each participant from preprocessed diffusion MRI data using automatic fiber tracking and atlas-guided tract recognition with bilateral cerebellar hemispheres as regions of avoidance (DSI Studio). Microstructural metrics were computed from these reconstructed tracts to represent CC integrity.
Results: Increases in NfL were associated with increases in CC radial diffusivity (r2 = 0.845) and decreases in CC quantitative anisotropy (r2 = 0.675) and fractional anisotropy (r2 = 0.967). Changes in NfL and CC integrity were moderately related to changes in post-concussive symptoms (r2 = 0.366–0.772).
Conclusion: The relationships observed in these preliminary data suggest that changes in serum NfL may be sufficiently sensitive to detect subclinical, ‘subconcussive’ axonal injuries in collision sport female athletes.
172 A novel method to evaluate and treat disorders of the self: validation of an integrative neuropsychological model of a “Sense of Self”
Brick Johnstonea, Jane Walshb, Haulie Dowdb
aShepherd Center, Atlanta, USA, bNUI Galway, Galway, Ireland
ABSTRACT
A major weakness in the neurorehabilitation of brain disorders relates to limited understanding of the neuropsychological foundations of disorders of the self (e.g., asomatognosia, anosagnosia, alexithymia, mirror misidentification). These disorders are most commonly characterized as disorders of “self-awareness” and hypothetically include the inability to be aware of distinct aspects of the self (e.g., physical, psychological, etc.). However, a universal model to explain all disorders of the self has been lacking until recently.
An Integrative Neuropsychological Model of the Self
A neuropsychological model has recently been proposed that can explain all disorders of the self (Johnstone et al., 2021) and lead to more effective treatment. Specifically, it has been proposed that the right hemisphere association area (RHAA) integrates all neurologic inputs (sensations) and outputs (mental experiences such as thoughts, emotions) into a unified experience that is experienced as a “sense of self.” This “sense of self” is experienced as a sense of “mineness” that allows for the experience of relatedness (i.e., degrees of relationship to “me”).
Disorders of the Self
The model can be explained by applying it to disorders of the self. For example, asomatognosia involves the disintegration of tactile sensations leading to a decreased sense of “mineness” of the left arm (i.e., not “my” arm), anosognosia involves the disintegration of attributes of the self (i.e., not “my” impairment), and alexithymia involves the disintegration of emotions (i.e., not “my” emotion). This model can also be applied to psychiatric disorders of the self (e.g., schizophrenia; not “my” thought) and depersonalization disorder (i.e., not “my” experience) and delusional misidentification disorders such as Capgras syndrome in which individuals recognize but deny a relationship to their family members (e.g., not “my” wife).
Character Traits and Experiences
Our research has also demonstrated that this integrative neuropsychological process can explain many relational experiences and character traits/experiences. For example, our research has demonstrated that intact RHAA functioning is associated with increased empathy in which the experiences of others are incorporated into the sense of self (i.e., your thoughts/emotions as “mine”). In contrast, inhibition of this sense of self has been shown to be the neuropsychological foundation of forgiveness (i.e., decreased focus on sense of injury to the self) and other “selfless” experiences (e.g., transcendence). Our international research teams have demonstrated these relationships across multiple cultures (Ireland, India, US) and religions (Hindu, Muslim, Christian, “nones”).
Treating Disorders of the Self
This model suggests that disorders of the self should be treated as disorders of dis-integration rather than awareness. Novel treatments for asomatognosa, anosognosia, alexithymia, and other disorders are reviewed such as use of mirrors to increase integration (i.e., sight of intact limb in mirror suggesting intact amputated limb), prism glasses, and virtual reality (e.g., rubber hand experiment).
173 The intersection of traumatic brain injury and homelessness
Stephanie Chassmana, Katie Calhoun, Blair Bacona, Sara Chaparro Rucoboa, Emily Goodwina, Kim Gorgensa, Daniel Brissona
aUniversity of Denver; Veterans Affairs, Los Angeles, USA
ABSTRACT
The rates of traumatic brain injury (TBI) are significantly higher among individuals experiencing homelessness compared to the general population. Up to half of individuals experiencing homelessness may have a TBI compared to the 12% lifetime prevalence rate among the general population. The relationship between TBI and homelessness is hypothesized as bi-directional, as factors associated with homelessness may increase the risk of TBI, while at the same time, factors associated with TBI may impact one’s housing stability. Additionally, accurate prevalence rates of TBI among individuals experiencing homelessness are difficult to obtain due to different methods of sampling participants and differing definitions of TBI; therefore, estimates may be underrepresented. Despite past research that has examined the relationship between TBI and homelessness, there are specific gaps in knowledge such as correlates and risk factors of TBI among individuals experiencing homelessness.
This study expands on previous research by describing with greater specificity, the rates, directionality, along with mental health correlates of TBI and homelessness.
Research questions include:
What are the rates of TBI among a sample of individuals experiencing homelessness?
Does a TBI experience precede or follow an initial period of homelessness?
What are the correlates of TBI prior to homelessness including self reported mental health variables?
Cross-sectional study design and purposive sampling across two sites in Colorado were utilized to interview a total of 115 English-speaking adults (ages 18–73). Quantitative questions examined rates of TBI, experiences of homelessness, time sequencing of TBI and homelessness events, and correlates of housing instability including self-reported mental health variables. First, a series of descriptive analyses were conducted to describe sample characteristics in terms of TBI variables as well as all independent variables. Dependent variables were chosen based on a review of previous literature, specifically literature that examines the relationship between mental health and housing stability. Binary logistic regression analysis was then conducted by regressing the 2-category mental health dependent variables on the independent variables which include demographic and TBI first variable. There were two dependent, self-report mental health variables: one measure of mental health challenges impacting housing stability and one measure of mental health.
Results show, out of 115 total participants, 71% reported a significant history of TBI. Out of the participants who reported a history of TBI, 74% reported TBI prior to their first experience of homelessness. Multivariate findings revealed that for participants who had a reported TBI prior to experiencing homelessness, they were less likely to have experienced housing instability due to a mental health issue or concern and were less likely to have a mental health or brain issue that would make it hard for them to live independently. Implications include prioritizing permanent supportive housing followed by other supportive services.
174 Post-concussion syndrome and post-traumatic stress disorder following combat-related mild traumatic brain injury: impact on long-term health-related quality of life
Andrew MacGregora, John Casachahuaa, Sarah Juricka,b, Cameron McCabea,b, Amber Doughertya,b
aNaval Health Research Center, San Diego, USA, bLeidos, Inc., San Diego, USA
ABSTRACT
Introduction: Mild traumatic brain injury (mTBI) was a signature wound of the conflicts in Iraq and Afghanistan, largely due to the preponderance of blast weaponry. Persistence of adverse sequelae following mTBI can lead to post-concussion syndrome (PCS). Because mTBI sustained during warfare also occurs in the context of a potentially traumatic event (i.e., combat), there is an additional risk of post-traumatic stress disorder (PTSD). Few studies have examined how PCS, PTSD, and their co-occurrence influences long-term health-related quality of life (HRQOL) among combat veterans.
Objective: To examine (1) the prevalence of PCS and PTSD in a 2-year period following combat-related mTBI, and (2) the association between PCS, PTSD, and long-term HRQOL.
Patients and Methods: The study sample included 564 individuals who had sustained an mTBI during combat between 2008 and 2012 and were enrolled in the Wounded Warrior Recovery Project (WWRP), a longitudinal study that examines patient-reported outcomes, including HRQOL. The WWRP questionnaire was administered on average 7.7 years following mTBI (range 5.8–11.5 years), and participants were assessed for physical and mental HRQOL using the 36-item Short Form Survey. For the 2-year period following mTBI, military medical databases were used to identify diagnoses of PTSD and PCS. Other variables were abstracted for adjustment purposes from point-of-injury medical records and included age at time of mTBI, sex, service branch, loss of consciousness, overall injury severity, and injury mechanism. Multivariable linear regression was utilized to examine the association between PCS, PTSD, and long-term HRQOL, while also testing for statistical interactions between PCS and PTSD.
Results Those in the study sample were an average age of 25.1 (SD = 6.1 years), mostly men (95.4%), in the US Army (67.2%), and injured by blast (97.3%). Less than half (43.8%) experienced loss of consciousness with mTBI and only 9.9% sustained other non-mTBI injuries that elevated their overall injury severity to serious-to-severe. The overall prevalence of PCS and PTSD was 19.3% and 22.9%, respectively. More specifically, 12.4% were diagnosed with PCS only, 16.0% with PTSD only, and 6.9% with both PCS and PTSD. In multivariable linear regression, PTSD was associated with declines in physical (β = −3.25, p = 0.001) and mental (β = −6.92, p < 0.001) HRQOL. There were no similar associations found with PCS. Interactions between PCS and PTSD were not statistically significant.
Conclusions: Both PCS and PTSD were diagnosed at a similar prevalence within 2 years following combat-related mTBI. However, only diagnosed PTSD was associated with subsequently lower HRQOL years after injury. Mental health professionals should be involved throughout the rehabilitation process to maximize patient well-being in the years after mTBI.
176 Gender differences in post-concussion symptoms among US Military Personnel
Andrew MacGregora, John Casachahuaa, Sarah Juricka,b, Amber Doughertya,b
aNaval Health Research Center, San Diego, USA, bLeidos, Inc., San Diego, USA
ABSTRACT
Introduction: Mild traumatic brain injury (mTBI) among military personnel results from injuries sustained during warfare and accidents related to operations and training. In the US military, women are the fastest growing demographic. Given a recent policy change allowing women to occupy combat occupations, the study of gender differences is a priority. Examining gender differences in post-concussion symptoms could inform screening and treatment protocols.
Objective: To examine gender differences in post-concussion symptoms among US military personnel who screened positive for mTBI. PATIENTS AND METHODS: The study sample included 3,883 individuals (3,542 men and 341 women) who screened positive for mTBI (i.e., probable mTBI) on the Post-Deployment Health Assessment (PDHA) between 2012–2021. A positive screen for mTBI was determined using the Brief Traumatic Brain Injury Screen on the PDHA. Fifteen post-concussion symptoms were assessed as present or not present. Additional self-reported information was abstracted for adjustment purposes, including blast exposure and post-traumatic stress disorder (PTSD). Multivariable logistic regression models were performed for each symptom, and assessed for gender differences while controlling for covariates.
Results: A higher proportion of women than men reported PTSD (33.4% vs. 28.1%, p = 0.036), whereas men more often reported blast exposure (33.3% vs. 12.3%, p < 0.001). Overall, the most common self-reported post-concussion symptoms were sleep problems (72.8%), back pain (72.3%), headache (67.2%), feeling tired or having low energy (62.9%), irritability (55.8%), and tinnitus (54.5%). In multivariable regression, women had higher odds than men of headache (OR 2.05, 95% CI 1.55–2.71), balance problems (OR 1.32, 95% CI 1.01–1.72), feeling tired or having low energy (OR 1.50, 95% CI 1.16–1.95), sensitivity to bright light (OR 1.42, 95% CI 1.11–1.81), and dimming of vision (OR 1.44, 95% CI 1.03–2.02), whereas men had higher odds than women of tinnitus (OR 1.42, 95% CI 1.12–1.80), hearing problems (OR 1.80, 95% CI 1.41–2.30), and back pain (OR 1.30, 95% CI 1.01–1.67). For all symptoms, PTSD was the strongest predictor, with ORs ranging from 2.47–6.32.
Conclusions: Post-concussion symptoms differed between US military men and women with probable mTBI. A key finding was the gender differences in sensory symptoms, with women reporting more visual and men reporting more auditory symptoms. Notably, cognitive difficulties, such as memory problems, difficulty concentrating, and difficulty making decisions, which are essential to operational performance, did not differ by gender. PTSD was strongly associated with all post-concussion symptoms, which suggests that an assessment of PTSD conducted simultaneously with mTBI screening is beneficial. As women continue their increased role in US military operations, the study of gender differences in outcomes following mTBI is essential for continued refinements to mTBI screening, treatment, and patient management.
177 Wet Wacky and Won’t participate in therapy: a case of obstructive hydrocephalus with persistent encephalopathy and parkinsonian features responsive to Carbidopa-Levodopa
Mollie Andreaea, Doctor Gemayaret Alvarez-Gonzaleza
aUniversity Of Miami Jackson Health System, Miami, USA
ABSTRACT
Case Diagnosis: A 73-year-old male with a right thalamic tumor complicated by obstructive hydrocephalus underwent tumor biopsy and third ventricle ventriculostomy presented with persistent encephalopathy and parkinsonian features demonstrated significant functional gains and improvement in encephalopathy after initiation of carbidopa-levodopa treatment.
Case Description: A 73-year-old male with several months of cognitive decline, gait disturbance, vestibular dysfunction, and urinary incontinence was found to have a right thalamic tumor with obstructive hydrocephalus. He underwent biopsy of the tumor and ventriculostomy of the third ventricle. Upon presentation to acute inpatient rehabilitation, the patient required moderate to maximum assistance for most mobility and activities of daily living. Prior to rehab the patient underwent an extensive work-up for encephalopathy which was negative except for a continuous EEG which demonstrated mild encephalopathy characterized by mild slowing. In the setting of poor initiation and mask-like facies, the patient was started on a trial of Carbidopa-Levodopa three times daily. Within 48 hours there was notable improvement in the patient’s cognitive status, mobility, and overall mood. The patient progressed to a minimum assist to supervision level and was discharge home with family.
Discussion: The differential diagnosis for patients who present with encephalopathy with parkinsonian features is extensive. It requires a thorough work-up to identify possible reversible as well as non-reversible causes. In this patient’s case, obstructive hydrocephalus was the suspected etiology, however minimal functional improvement was noted post-surgical intervention. While there are several studies that discuss the presence of parkinsonian features in patients with hydrocephalus to our knowledge there are only two other case reports that explored the use of carbidopa-levodopa in this patient population.
Conclusion: Encephalopathy is a common presenting symptom in patients with hydrocephalus. We present a unique case of obstructive hydrocephalus with persistent encephalopathy despite appropriate neurosurgical intervention that demonstrates the importance of considering dopaminergic agents to facilitate functional and cognitive improvement.
178 Different experimental paradigms of mild traumatic brain injury produce chronic neurodegeneration, neuroinflammation, and neuropsychiatric problems
Edwin Vazquez-Rosaa,b,c,d, Min-Kyoo Shina,b,c,d, Coral Cintron-Pereza,b,c,d, Kalyani Chaubeya,b,c,d, Sarah Barkera,b,c,d, Adora Ezepuee, Kate Lindleyg, Youngmin Yua,b,c,d, Ayush Vyasa,b,a,d, Jiwon Hyunga,b,c,d, John Broussardg, Hector De Jesús-Cortésh, David Arciniegasi, Ricardo Jorgei,j, Andrew Piepera,b,c,d
aDepartment of Psychiatry, Case Western Reserve University, Cleveland, USA, bGeriatric Research Education and Clinical Center (GRECC), Louis Stokes Cleveland VA Medical Center, Cleveland, USA, cHarrington Discovery Institute, University Hospitals Cleveland Medical Center, Cleveland, USA, dInstitute for Transformative Molecular Medicine, School of Medicine, Case Western Reserve University, Cleveland, USA, eThe Ohio State University, Colombus, USA, fHarrisburg Academy, Wormelysburg, USA, gDepartment of Neurobiology and Anatomy, The University of Texas McGovern Medical School, Houston, USA, hThe Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, USA, iBeth K and Stuart C. Yudofsky Division of Neuropsychiatry, Baylor College of Medicine, Houston, USA, jDepartment of Veteran Affairs, Michael E DeBakey VA Medical Center, Houston, USA
ABSTRACT
Around 1.7 million patients are diagnosed with traumatic brain injury (TBI) every year in the United States. Most of these cases are characterized by relatively rapid recovery of acute symptoms. However, repetitive TBIs, such as are common with contact sports or within military operations, are associated with a more chronic course and greater complications. In sports, TBI is predominantly a contact-based concussive injury. In the military, by contrast, TBIs are typically of a more mixed variety, entailing varying components of concussive injury, acceleration/deceleration injury, and blast exposure. Neuropathological changes associated with all forms of TBI may progress over time and increase the risk of developing other neurodegenerative conditions, including Alzheimer’s disease, Parkinson’s disease, vascular dementia, and chronic traumatic encephalopathy. We have investigated the chronic consequences of TBI using two mouse models: the electromagnetic controlled cranial impact (CCI) model, which represents an isolated concussive injury, and the overpressure multimodal TBI model (mmTBI), which represents a mixture of concussion, acceleration/deceleration, and blast wave exposure. In the CCI model, we additionally examined both repeated mild TBI (rmTBI) and single mild TBI (smTBI), as repeated injury is associated with more severe sensorimotor, cognitive, and behavioral deficits in the acute stage of TBI. In the current set of experiments, we found that TBI resulting from both the CCI and multimodal models cause chronic learning and memory impairment (in the Morris water maze) six months after injury. However, only CCI causes anxiety-like behavior (in the elevated zero maze) at this time point. From a histopathological standpoint, TUNEL assay, in combination with NeuN staining, demonstrated that both models are associated with significantly increased DNA damage and neuronal cell loss in the cortex and hippocampus. Interestingly, both brain regions also showed a significantly increased number of microglia with lipid droplet accumulation, which is a characteristic of dysfunctional and pro-inflammatory microglia and has not been previously reported in TBI. Collectively, our results provide new insight into the chronic cognitive, affective, and neuropathological outcomes of multiple forms of TBI.
179 INCOG 2.0 guidelines for cognitive rehabilitation following traumatic brain injury: what’s new?
Mark Bayleya,b,c, Peter Bragged, Diana Velikonjae, Professor Leanne Togherf, Robin Greena,b, Amanda McIntyreg,h, Shannon Janzeng, Amber Harnettg,h, Shawn Marshalli,j, Robert Teasellg,h,k, Adam McKayd,l,m, Jessica Trevena-Petersd,l,m, Eliyas Jeffaya,b, Ailene Kuaa,b, Eleni Patsakosa,b,c, Catherine Wiseman-Hakesa,b,n, Lyn Turkstran, Mary Kennedyo, Jacinta Douglasp, Penny Welch-Westk, Professor Jennie Ponsfordd,l,m
aUniversity Health Network-Toronto Rehabilitation Institute, Toronto, Canada, bKITE Research Institute, Toronto, Canada, cTemerty Faculty of Medicine, University of Toronto, Toronto, Canada, dMonash University, Melbourne, Australia, eHamilton Health Sciences, Hamilton, Canada, fFaculty of Health Sciences, The University of Sydney, Sydney, Australia, gLawson Health Research Institute, London, Canada, hParkwood Institute, London, Canada, iThe Ottawa Hospital-Rehabilitation Center, Ottawa, Canada, jUniversity of Ottawa, Ottawa, Canada, kUniversity of Western Ontario, London, Canada, lTurner Institute for Brain and Mental Health, Melbourne, Australia, mMonash Epworth Rehabilitation Research Center, Melbourne, Australia, nSchool of Rehabilitation Science, McMaster University, Hamilton, Canada, oChapman University, Irvine, USA, pLa Trobe University, Melbourne, Australia
ABSTRACT
Background: Despite hundreds of clinical trials in cognitive rehabilitation after moderate or severe traumatic brain injury (TBI), translating these findings into clinical practice remains challenging. It is critical to keep clinical practice guidelines up-to-date by integrating the latest evidence. It has been eight years since the first iteration of the INCOG clinical practice guidelines was published. Much has happened since 2014, and a considerable body of evidence has been published in the various domains of cognitive rehabilitation. The objective of this initiative was to re-convene the international group of cognitive researchers and clinicians (known as INCOG) to develop INCOG 2.0: Guidelines for Cognitive Rehabilitation Following TBI. This presentation aims to raise awareness of the changes in cognitive rehabilitation best practices.
Methods: The Guidelines Adaptation and Development Cycle was used to update the current recommendations and derive new ones. The INCOG team met virtually and reviewed the literature published since the original INCOG (2014) to update the recommendations and decision algorithms. The team then prioritized the recommendations for implementation and modified the audit tool accordingly to evaluate adherence to best practices.
Results: The INCOG update contains 80 recommendations (25 level A, 15 level B and 40 level C), of which 27 are new. Recommendations were developed for post-traumatic amnesia (PTA), attention, memory, executive functions and cognitive communication. There were 38 recommendations pertaining to: Assessment (10 recommendations), Principles of Cognitive Rehabilitation (6 recommendations), Medications to Enhance Cognition (10 recommendations), Tele-Assessment (5 recommendations), and Telerehabilitation Intervention (7 recommendations). One recommendation was supported by level A evidence, 7 by level B evidence and all remaining recommendations were level C evidence. There were 6 recommendations for PTA, 11 for Attention, 8 for Memory, 8 for Executive Functions and 9 for Cognitive-Communication. New to INCOG are recommendations for telehealth-delivered cognitive assessment and rehabilitation. Evidence-based clinical algorithms and audit tools for evaluating the state of current practice are also provided.
Conclusion: Concerted efforts are necessary to overcome the barriers to implementing clinical practice guidelines. Each topic is similar, with an overview of the recommendations, tabulated references, rationales for the recommendations, algorithms to assist treatment decisions, and audit tools. This updated set of cognitive rehabilitation guidelines was developed using a rigorous process and provides updated guidance for clinicians. Evidence-based cognitive rehabilitation guided by these recommendations should be offered to individuals with TBI. Despite the advancements in TBI rehabilitation research, further high-quality studies are needed to better understand the role of cognitive rehabilitation in improving patient outcomes following TBI. In a new era of rapid reviews and living guidelines, innovations to the methods for updating INCOG recommendations also warrant consideration.
180 Lessons learned from moving to living guidelines – the canadian guideline for rehabilitation of adults with moderate to severe traumatic brain injury experience
Ailene Kuaa,b, Judith Gargaroa,b, Eleni Patsakosa,b,c, Olga Yaroslavtsevaa,b, Robert Teaselld,e,f, Shannon Janzenf, Amber Harnette,f, Emily Barretta, Phoebe Bennetta, Mark Bayleya,b,c
aUniversity Health Network- Toronto Rehabilitation Institute, Toronto, Canada, bKITE Research Institute, Toronto, Canada, cTemerty Faculty of Medicine, University of Toronto, Toronto, Canada, dSt. Joseph’s Health Care, London, Canada, eParkwood Institute, London, Canada, fLawson Health Research Institute, London, Canada
ABSTRACT
WEBSITE: https://braininjuryguidelines.org/modtosevere/
Background: Clinical Practice Guidelines (CPGs) are a well-accepted tool for improving health care and assisting healthcare professionals in making evidence-based clinical decisions. Bridging the gap between research and clinical practice, CPGs aim to enhance the quality and consistency of care to improve patient health outcomes. The development of CPGs is contingent upon a methodologically rigorous process involving identification of research literature, achieving clinical consensus, and dissemination/implementation of the resulting recommendations/tools. Given the increasing volume of research published on moderate-to-severe Traumatic Brain Injury (TBI) rehabilitation, a living CPG infrastructure is necessary to ensure recommendations remain current. The goal of this project was to transform the current guideline update model whereby updates traditionally occur at long intervals (e.g., every three to five years) to a living update process.
Methods: This process was developed to ensure that recommendations are responsive to rapidly emerging evidence, increasing CPG validity. The process:
The Evidence-Based Review of Moderate-to-Severe Acquired Brain Injury (ERABI) team performed a systematic review of the TBI literature up to 2022 and prepared evidence summary tables to present to expert panels.
Expert panels of people with relevant clinical, research and lived experience were selected for each guideline section to review the materials. In a series of meetings, each expert panel reviewed and discussed the new and existing evidence, evaluated its quality, and added, removed or modified recommendations and tools as needed.
The panels finalized wording and voted on proposed updates to content and levels of evidence via online survey to approve the final version. A minimum of 75% agreement by 80% of the panel was required.
The updates were translated into French and disseminated in both languages through the guideline website, professional publications, presentations and networking.
Results: Over the past year, this review process has yielded new and updated recommendations in the following sections:
Components of the Optimal TBI Rehabilitation System (new = 4, updated = 64)
Assessment and Rehabilitation of Brain Injury Sequelae: cognitive and cognitive communication rehabilitation (new = 21, updated = 31); fatigue and sleep disorders (new = 3, updated = 1); pain and headache management (new = 2, updated = 4); medical/nursing management (new = 9, updated = 5); psychosocial/adaptation issues (new = 4); and neurobehavior, mental health and substance use disorders (new = 36). In addition, a new module addressing sexuality, changes in intimacy and relationships post moderate-to-severe TBI was developed (new = 6). The following sections are still under review: comprehensive assessment of the person with moderate-to-severe TBI, and management of disorders of consciousness.
Conclusions: New recommendations generated through this “living” process are beneficial to keeping clinicians current with best practice evidence. The support for this process by end users validates the need for continued access to evidence-based guideline recommendations and tools.
181 Evaluating the efficacy of a multidisciplinary rehabilitation program for the treatment of persistent post-concussive symptoms
John Olvera,b,c, Bianca Fedelea,b,c, Rose Achera,b, Dean McKenziea,c
aEpworth HealthCare, Melbourne, Australia, bEpworth Monash Rehabilitation Medicine (EMReM) Research Unit, Melbourne, Australia, cMonash University, Melbourne, Australia
ABSTRACT
Background: Following a concussion, individuals commonly experience various neurological, physical, cognitive, and emotional symptoms as a result of disrupted brain function. Whilst the majority of individuals will recover, a subset experience persistent post-concussive symptoms that can affect recovery and daily functioning. This group can benefit from interventional, multidisciplinary rehabilitation provided by Epworth HealthCare’s outpatient Rehabilitation Concussion Clinic.
Study Aims: This study aimed to evaluate the effect of an individually tailored multidisciplinary rehabilitation program on the recovery of persistent post-concussive symptoms between clinic admission and discharge. It also aimed to identify the post-concussive symptoms that persist even after rehabilitation treatment, and evaluate the potential predictors of symptom persistence (gender, referral time to clinic and number of symptoms on clinic admission).
Methods: The Oregon Post-Concussion 23-item Symptom Checklist was administered on clinic admission and repeated on clinic discharge. Patients rate the presence and severity of symptoms (ranging from 0 – none to 6 – severe). Symptom scores are summed to produce four subscale scores (physical, thinking, emotional and sleep) and a total score. Patients self-report their daily activity levels (%) compared to normal. On clinic admission, a rehabilitation physician’s initial examination, which includes symptom presentation, directs an individually tailored rehabilitation program (i.e., combination of neuropsychology, physiotherapy, occupational-vocational therapy, exercise physiology and/or speech therapy).
Results: The analytic sample comprised 302 patients treated within the concussion clinic. Mean age was 36.1 years (standard deviation [SD]: 14.9) and 50.7% were female. Patients received rehabilitation therapy for a mean of 284.3 days (SD: 247.5). Overall, there was a statistically significant decrease in patients mean total checklist and subscale scores by clinic discharge (p < 0.001). Patients self-reported a significant increase in their daily activity levels from clinic admission (41.9%) to clinic discharge (76.2%). The most common symptoms with persistence on clinic discharge included: – fatigue, visual problems, numbness/tingling, pain and headache. Poisson regression found that referral time was a significant predictor for the persistence of all five symptoms (p < 0.05). When compared to patients with an early clinic referral (≤ 3 months post injury), patients with a late clinic referral (> 3 months post injury) displayed significantly higher levels of persistence of fatigue (31.9 vs 57.8%), visual problems (27.3 vs 50.0%), numbness/tingling (17.4 vs 54.5%), pain (21.1 vs 49.0%) and headache (22.0 vs 52.7%). Number of admission symptoms was a significant predictor for fatigue, pain and headache only. Gender did not significantly predict persistence of symptoms.
Conclusions: For individuals with persistent post-concussive symptoms, meaningful gains in terms of recovery and return to daily activities were achieved with an individually tailored rehabilitation program. Referral time for treatment can have a significant impact on recovery, and so a focus should be on the earlier detection and treatment of persistent post-concussive symptoms.
182 Efficient assessment of brain fog and fatigue: development of the fatigue and altered cognition scale (FACs)
Timothy Elliotta, Yu-Yu Hsiaob, Kathleen Randolphc, Randall J. Urbanc, Melinda Sheffield-Moorec, Richard B. Pylesc, Brent E. Maselc, Tamara Wexlerd, Traver J. Wrightc
aTexas A&M University, College Station, USA, bUniversity of New Mexico, Albuquerque, USA, cUniversity of Texas Medical Branch, Galveston, USA, dNYU Langone Health, New York City, USA
ABSTRACT
Background: Individuals living with chronic health conditions often suffer from profound, debilitating fatigue with accompanying “brain fog.” These co-occurring symptoms are observed among those with traumatic brain injury (TBI) and among survivors of SARS-CoV-2 (COVID-19) who are described as “long haulers.” Some studies of co-occurring brain fog and fatigue use over a dozen, time-intensive neuropsychological measures to isolate deficits, and these may be insensitive to patient-reported changes of symptom severity. Currently, an efficient, psychometrically sound instrument to assess these co-occurring problems is not available. To meet this need, we developed the Fatigue and Altered Cognition Scale (the FACs), and report its initial psychometric properties.
Methods: The research team generated potential items for the FACs based on their clinical experience, and the relevant literature. Twenty possible items, including ten each for the assessment of brain fog (“altered cognition”) and fatigue, were formatted into “electronic” visual analogue rating scales (eVAS) for ease in administration and scoring. Each item was anchored with extreme responses from “not at all” to “extremely,” and item responses were set proportionally to obtain a 0 to 100 score. Prospective participants responded to an online survey. Of the 776 individuals that responded, 519 consenting participants (73% women) provided useable data, 204 of whom self-reported a history of TBI (mean age = 42 years). Internal consistency and reliability values were calculated. Construct validity was examined with a confirmatory factor analysis (CFA). A measurement invariance test of the two latent constructs (altered cognition and fatigue) among participants with and without TBI (n = 315; mean age = 39) was conducted.
Results: All items demonstrated a normal distribution. Both factors evidenced good internal consistency (both = 0.95). The omega reliability values for both factors were favorable (0.95). CFA results supported the two-factor model and item loadings as expected. Measurement invariance results found that the factor structures were the same between the two groups (configural invariance). Furthermore, comparisons of the FACs scores between individuals in the TBI and non-TBI groups reflected their differences in the latent FACs levels (scalar and strict invariance).
Conclusions: Initial psychometric analyses support the factor structure and item integrity of the FACs. Participants in both groups provided a wide range of responses, suggesting the response options provided by the eVAS were an appropriate and helpful format. The fatigue and altered cognition scales effectively differentiated between those with and without self-reported TBI. With its unique eVAS format, the FACs appears to be an efficient and useful instrument to assess co-occurring fatigue and brain fog in clinical practice and research. Further study of its validity, reliability, and potential use in monitoring patient response to treatment is recommended. Its potential use with patients with other chronic health conditions also merits investigation.
183 “They treat you like a person, they ask you what you want”: quality support grounded in the lived experience of people with neurological disability, close others, and disability support workers
Megan Toppinga,b, Jacinta Douglasa,b, Di Winklera,b
aLa Trobe University, Melbourne, Australia, bSummer Foundation, Melbourne, Australia
ABSTRACT
Background and Objectives: People with acquired neurological disability (i.e., acquired brain injury, spinal cord injury and neurodegenerative diseases) experience a range of physical, cognitive and communication impairments and therefore often require paid support to live independently in the community. Despite the importance of support for people with neurological disability, there is a dearth of evidence from the lived experience perspective as to what facilitates quality support. This project aimed to build a holistic understanding of the factors that influence the quality of support to inform practice and policy and improve support quality for people with acquired neurological disability.
Method: A series of three constructivist grounded theory studies were conducted to explore the perspectives and experiences of people with lived experience of paid disability support. Twelve adults with acquired neurological disability (5 – acquired brain injury, 5 – multiple sclerosis, 1 – spinal cord injury, 1 – other neurological disability), ten close others of people with neurological disability and complex needs (9 – acquired brain injury, 1 – cerebral palsy) and twelve disability support workers participated in in-depth interviews. Qualitative analysis guided by grounded theory methodology was conducted for each perspective and a model of quality support was developed from each study. Following independently analyzing the perspectives, the identified themes and subthemes were compared and corroborated to build a holistic model of support grounded in the lived experience of people with disability, close others, and disability support workers.
Results: With overwhelming congruence between the three perspectives, the model of quality support emerged as a multi-level system with factors at the dyadic space between the person with disability and their support worker, the support team level and the broader sector and system levels. Primarily, the support worker needs to recognize the person as an individual and see them as the expert in their own support needs, and the dyad needs to work well together. Beyond the dyadic space, a committed support team, who are interested, competent and willing to provide support is necessary. At the sector level, working conditions influence whether support workers feel valued and are held accountable, and in turn delivering quality support. Overwhelmingly, people with disability need to have choice over their supports to facilitate quality support and feel in control of their lives.
Conclusions: The quality of support is influenced by a complex mix of interrelated factors. Most critically, and in line with the rights of people with disability and individualized funding principles, people with disability need to have authentic choice over their supports and be seen as the expert in their support needs. These findings have important policy and practice implications and advance our learnings to improve the quality of support for people with neurological disability.
184 Multimodal open-label study of apomorphine for prolonged disorders of consciousness
Leandro R.D. Sanza,b, Emilie Szymkowicza,b, Nicolas Lejeunea,b,c,d, Estelle A.C. Bonina,b, Arianna Salaa,b, Rajanikant Pandaa,b, Aurore Thibauta,b, Nadia Dardennee, David Dikensteinc, Sébastien Van Goethemc, Didier Ledouxb,f, Roland Hustinxg, Steven Laureysa,b,h, Olivia Gosseriesa,b
aComa Science Group, GIGA Consciousness, University of Liège, Liège, Belgium, bCentre du Cerveau2, University Hospital of Liège, Liège, Belgium, cCentre Hospitalier Neurologique William Lennox, Cliniques Universitaires Saint-Luc, Ottignies-Louvain-la-Neuve, Belgium, dInstitute of Neurosciences, University of Louvain, Louvain, Belgium, eB-STAT, Public Health Sciences Department, University of Liège, Liège, Belgium, fIntensive Care Medicine Department, University Hospital of Liège, Liège, Belgium, gNuclear Medicine Unit, Medical Physics Department, University Hospital of Liège, Liège, Belgium, hJoint International Research Unit on Consciousness, CERVO, Brain Research Center, University of Laval, Québec, Canada
ABSTRACT
Introduction: Dopamine pathways have recently been identified as a central hub for consciousness. Dopaminergic disconnection is associated to a disruption of connectivity and functionality especially of the default mode network (DMN). Considering this evidence, therapeutic neuromodulation through dopamine agonists, as apomorphine, could potentially mediate macroscopic network alterations.
Methods: Six patients with disorders of consciousness (DoC) underwent resting-state high-density electroencephalogram (hdEEG), 18 F-fluorodeoxyglucose positron emission tomography (18 F-FDG-PET) and behavioral assessments using the Coma Recovery Scale-Revised (CRS-R) before and after 30-day of subcutaneous apomorphine treatment. We investigated apomorphine-related neural mechanisms at the whole-brain and regional levels considering, among others, the DMN (i.e., parietal, temporal, and frontal areas).
Results: hdEEG connectivity (weighted phase lag index) and integration (participation coefficient) in the alpha frequency were significantly increased after apomorphine at the whole-brain level. More specifically, significant increases were observed for the alpha parieto-temporal connectivity and the frontal integration. 18 F-FDG-PET brain metabolism indicated the highest proportion of hypometabolic voxels in the DMN compared to controls (44.8%) before apomorphine and a decrease in the proportion of hypometabolic voxels particularly in the DMN (−3.2%) as well as an increase in whole-brain standardized uptake value (+5.2%) after apomorphine. CRS-R conscious behaviors increased in 5/6 patients after apomorphine.
Conclusion: Improvements in connectivity, integration, metabolism, and behaviors observed after apomorphine treatment highlight its potential impact to modulate therapeutic targets such as the DMN and promote consciousness recovery in patients with DoC.
185 Chasing biomarkers in post-concussion syndrome: baseline data from a randomized controlled trial
Peter P. Eggertsena, Rikke Katrine Jentoft Olsenb, Johan Palmfeldtb, Asger Roer Pedersena, Jørgen Feldbæk Nielsena
aHammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Aarhus, Denmark, bResearch Unit for Molecular Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
ABSTRACT
Introduction: Mild traumatic brain injury, commonly known as concussion, may lead to debilitating long-term symptoms which can be defined as post-concussion syndrome (PCS). Although promising biomarkers have been identified in the acute phase of concussion, the pathophysiology behind the chronic symptoms of PCS remains a mystery. The aim is to study the pathophysiology of PCS by measuring blood-based biomarkers. The hypothesis is that the serum concentrations of neurofilament light chain (NFL), kynurenine metabolites, and inflammatory markers are significantly different in PCS patients compared to a healthy control group.
Methods: Blood samples were available from young patients with PCS (15–30 years old) enrolled in a recently published RCT study (PMC6933237). At baseline (3–4 months after the concussion), 86 blood samples were available. We recruited 120 age-matched healthy controls from the Blood Bank at Aarhus University Hospital based on a power calculation using NFL as the primary outcome. Serum concentrations of NFL were measured using the ultra-sensitive single-molecule array technology. We measured the kynurenine metabolites by developing a novel method using high-performance liquid chromatography-mass spectrometry. Inflammatory markers were measured with a multiplex assay (Luminex). We used the two-sample t-test or the Wilcoxon rank-sum test to compare PCS patients and healthy controls.
Results: We found no significant differences in NFL concentrations on a group level (p = 0.22). However, a subgroup of PCS patients (9.3%) had NFL concentrations above the age-specific clinical reference limit (> 9.9 ng/L), which was only the case in 4% of the controls. PCS patients had 10–25% lower concentrations of 3-hydroxykynurenine (p = .04), tryptophan, kynurenine, and kynurenic acid compared to healthy controls (p < 0.0001). We found no significant differences in quinolinic acid concentrations (p = 0.73). The inflammatory markers, monocyte chemoattractant protein-1 (MCP-1) and eotaxin were 25–40% lower in PCS patients compared to healthy controls (p < 0.0001), while no differences were found in interferon gamma-induced protein 10, interleukin 8, and macrophage inflammatory protein. There was a trend of higher concentrations of tumor necrosis factor alpha in PCS patients, but the results did not reach significance (p = 0.08).
Discussion: Our results show that several biomarkers are altered in PCS patients compared to healthy controls. Interestingly, low levels of kynurenine metabolites and MCP-1 have consistently been shown in major depressive disorder, which has clinical similarities to PCS. Surprisingly, we found no significant differences in NFL concentrations on a group level. However, a small subset of patients with PCS may still have increased concentrations, which can indicate structural damage within the central nervous system. In conclusion, this study provides novel insights into possible pathophysiological mechanisms behind PCS. The next step is to analyze data from a follow-up visit after 6 months using a linear mixed model. This data will be presented at the conference.
186 Epidemiology of concussion in Denmark from 1999–2018: a nationwide cohort study
Peter P. Eggertsena, Pia Cordsenb, Søren Paaske Johnsenb, Jørgen Feldbæk Nielsena
aHammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Aarhus, Denmark, bDanish Center for Clinical Health Services Research, Aalborg University, Aarhus, Denmark
ABSTRACT
Introduction: Mild traumatic brain injury, commonly known as concussion, is the most common type of head injury diagnosed in the emergency wards. Although most patients recover, 10–15% develop long-term symptoms such as headache, depression, and severe fatigue. Several studies have shown that concussion may negatively affect attachment to the labor market, income, the use of general practitioners, and even increase the risk of suicide. Despite the severe consequences, knowledge of the incidence of concussion is limited and varies widely between studies and countries. For example, the annual number of cases in Denmark has been reported to be as low as 10.000 and as high as 25.000 in the same time period. Accurate information on incidence is crucial to take preventive measures and convince stakeholders and politicians that treatment of late complications of concussion is necessary and economically feasible.
Aim: To determine the incidence and prevalence of concussion in Denmark and explore the development over time.
Methods: This was a registry-based cohort study that included all cases of concussions from Danish hospitals between 1999–2018. Data were retrieved from the National Patient Registry (NPR), and the inclusion criteria were the ICD-10 code for concussion (DS060), and a national Danish code for “observation for concussion” (DZ033D). Data from the general population were extracted from StatBank Denmark.
Results: The incidence rate of concussion in 2018 is almost doubled in the youngest and oldest age groups compared to the incidence rate in 1999. Interestingly, the incidence rate has significantly dropped in men and is now comparable to the incidence rate observed in women. In 2018, the total incidence is 306 pr. 100.000 person-years and it has been stable since 1999. The prevalence was estimated to be 4.8% in 2018 which is comparable to common lifestyle diseases such as diabetes.
Conclusion: A large proportion of the Danish population may be living with long-term symptoms of concussion. Although the total incidence is stable, an increased incidence was found in children and the elderly. This will be further explored by including clinical data on the admissions (such as trauma mechanisms) and data will be presented at the conference.
187 Positive behavior support and goal attainment scaling in adults with acquired brain injury
Kate Goulda,b, Jennie Ponsforda,b, Amelia Hicksa,b, Tim Feeneyc
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia, cBelvedere Health Services and the Mill School, Essex Junction, USA
ABSTRACT
Challenging behaviors after acquired brain injury (ABI) can cause distress and reduced community participation. Evidence-based interventions which result in clinically significant improvement are needed. Positive Behavior Support (PBS) interventions, such as PBS+PLUS, are person-driven and context-sensitive approaches which aim to improve quality of life and enhance behavioral self-regulation. This study aimed to expand the empirical outcomes of a recent waitlist-controlled trial of PBS+PLUS by examining individualized goal attainment. Participants were 44 adults with severe ABI sustained on average nine years previously (Range = 0.6–26). Using Goal Attainment Scaling, 182 goals were collaboratively developed with the person with ABI and their natural supports, focussing on psychological wellbeing, interpersonal relationships, routines and self-care. By the end of 12-month intervention, 91.8% of goals were achieved and 58.8% exceeded their expected outcome. These findings indicate high levels of personally meaningful outcomes in a broad range of life-domains can be obtained for participants with severe ABI using PBS+PLUS. Whilst these results should be considered in combination with the findings of the waitlist-controlled trial, they do contribute to the growing literature regarding the benefits of PBS for enhancing quality of life.
188 “I’ve never been positive … I am now.” Participant perspectives of a positive behavior support intervention (PBS+PLUS) for community living individuals with ABI and their close others
Jennie Ponsforda,b, Kristian Holthb, Kate Goulda,b, Amelia Hicksa,b, Penelope Analytisa,b
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia
ABSTRACT
Challenging behaviors are common following moderate to severe acquired brain injury (ABI). These behaviors cause relationship and community participation difficulties, and are a significant source of stress for many individuals with ABI and their close others (COs). A Positive Behavior Support (PBS) intervention, termed PBS+PLUS, aimed to collaboratively assist individuals with ABI to build meaningful lives and self-regulate their behavior. This study explored the perspectives of individuals with ABI and COs (family members, friends and carers) who had completed an individualized 12-month PBS+PLUS intervention. Fifty- two individuals participated in semi-structured interviews and a thematic analysis of interview transcripts was undertaken. Four interrelated themes were identified – Openness to Change, Embeddedness, Clinician Connection and Preparedness for the Future. Participant perceptions of, and engagement with, PBS+PLUS were influenced by an attitude of openness to new ideas and by the intervention itself. Achieving contextual relevance allowed the intervention to become embedded in participants’ lives and the client-clinician relationship was central to participants’ positive experiences. While most participants felt better equipped to cope with the future, some experienced difficulties transitioning to post-intervention life. These results suggest PBS+PLUS may assist individuals with ABI to lead meaningful lives and more confidently overcome behavioral challenges, while encouraging supportive and empowered COs.
189 Perspectives of clinicians on delivering a positive behavior support intervention for challenging behaviors following acquired brain injury
Kate Goulda,b, Penelope Analytisa,b, Amelia Hicksa,b, Jennie Ponsforda,b
aTurner Institute for Brain and Mental Health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia
ABSTRACT
Challenging behaviors are distressing sequelae for people with acquired brain injury (ABI) and their families. Positive Behavior Support (PBS) is a collaborative approach addressing challenging behaviors. This qualitative study explored clinicians’ experiences of a 12-month intervention (PBS+PLUS) for adults with ABI and their family/carers. Semi-structured interviews were conducted with eight clinicians trained in neuropsychology (n = 5), occupational therapy (n = 3), speech pathology (n = 2), with two clinicians trained in two disciplines. Interviews were thematically analyzed (Braun & Clarke, 2006). Three themes were identified: Shifting clinical identity; Working as equals; Adapting to the environment. Participants experienced PBS+PLUS as a difficult approach to learn but one which improved their practice, increasing directness with clients and comfort with their clinical fallibility. PBS+PLUS involved giving clients equal status in the clinician–client relationship which for some clients and families was challenging. Finally, PBS+PLUS was perceived as difficult to implement in some work settings (e.g. involving high staff turnover) but other settings easily adopted the approach. Clinicians’ recommendations for future implementations included thorough training and supervision, and setting of client expectations. With increasing interest in PBS as an approach addressing challenging behaviors after ABI, these findings inform capacity-building projects for community clinicians.
190 “This group … I felt like I was medicating myself from this cyberscam illness that was living with me.” A qualitative evaluation of co-designing cybersafety training resources with and for people with acquired brain injury
Kate Goulda,b, Jao Carminatia,b, Jennie Ponsforda,b
aTurner Institute of Brain and Mental Health, Monash University, Melbourne, Australia, bMonash-Epworth Rehabilitation Research Center, Melbourne, Australia
ABSTRACT
Background and Objectives: Online scams are increasingly prevalent and distressing. Individuals with acquired brain injury (ABI) may have unique risk factors and vulnerability to online scams for which tailored cyberscam interventions are required. To address this, a co-designed approach was utilized to collaboratively develop cybersafety resources with people with living expertise of ABI and scams. In depth examinations of the co-design experience is needed to inform future utilization of this methodology within this and other research endeavors.
Method: Adults who took part in up to three focus groups to co-design cybersafety training resources were invited to participate. Seven cyberscam survivors with ABI and one ABI carer participated in one-on-one semi-structured qualitative interviews exploring their co-design experiences. Six-phase reflective thematic analysis was conducted to produce an understanding of the key themes and develop a thematic map.
Results: All participants shared positive co-design experiences, which were conceptualized across six themes. Group Bonding: An overwhelming sense of support emerged amongst peers and facilitators through a shared purpose. Taking Ownership: Participants felt a sense of ownership by creating their own intervention and felt empowered by their agency in helping others. Validated and Valued: Taking the lead during discussions increased their confidence and self-esteem. Stronger Scam Awareness: Participants learnt about scams and recognized their personal vulnerability. Normalizing Scams: their sense of shame was reduced by openly sharing personal stories without judgment and hearing their respected peers talk about being scammed. Staying Connected: Participants identified a desire for ongoing training and involvement in peer-led groups to expand the project outcomes. Considerations for adjustments to support communication, memory impairments and fatigue were recommended.
Conclusions: Participant accounts of the co-design experience extended beyond project and resource design and resulted in unanticipated therapeutic benefits relating to increased insight and emotional recovery from feelings of shame. Potential mechanisms underpinning this were the peer group format and opportunities to make genuine contributions. Recommendations for informing future cybersafety interventions and generalizing these positive co-design experiences in non-cybersafety projects will be discussed.
191 Critical factors for safe driving in young adults with cerebral palsy – a pilot study
Per-Ola Rikea, Carl Fredrik Eliassena
aSunnaas rehabilitation Hospital, Nesoddtangen, Norway
ABSTRACT
Objective: Investigate medical and neuropsychological variables associated with driver’s license status and driving behavior in young adults with Cerebral Palsy (CP).
Methods: This retrospective follow-up cohort study included 17 young adults with CP, 3 men and 14 women, that previously had passed a multidisciplinary driving assessment prior to driver’s license training. The follow-up survey covered data from the driving training, vehicle data, self-reported driving behavior and measures of perceived pain, fatigue and driving self-efficacy. These data were analyzed in comparison with retrospective medical and neuropsychological data retrieved from the participants’ journals from the driving assessment.
Results: Eleven participants had obtained driver’s license at the time of follow-up, the majority drove a regular car and 5 participants were not in need of adaptations in the car. Both the driving and non-driving cohort portrayed some cognitive difficulties, however, impairments in visual attention, processing speed and executive function were most frequent among the non-drivers. The majority of the drivers did not report any compensatory driving behaviors. Four drivers had been involved in traffic accidents, two of these were involved in multiple accidents. Levels of pain or fatigue were not associated with driving behavior. Almost half of the drivers reported low driving self-efficacy.
Conclusion: This study shows that many people with CP become safe and confident drivers, however, one third of the participants did not obtain a valid driver’s license, probably due to sensory-motor and cognitive impairments. In addition, many drivers displayed reduced driving self-efficacy and had been involved in accidents. Thus, when assessing the health requirements for driving in persons with CP, clinicians need to give realistic prognostics based on a clinical assessment before the arduous and costly process that obtaining a driver’s license represent.
193 Fast multiplex detection of mild traumatic brain injury based on a novel magnetic particle system
Jiyoung Kima, Mina Kimi,j, Heelak Choia, Hye Yeon Choia, Byul Kima, Hanna Yoond,h, Young Sun Rob,d, Byung-Mo Ohc,e,f, Sang Hoon Songg, Yoo-bok Choa, Nakwon Choii,j, Yong-Gyun Junga
aEzdiatech, Anyang-si, South Korea, bDepartment of Emergency Medicine, Seoul National University Hospital, Seoul, South Korea, cDepartment of Rehabilitation Medicine, Seoul National University Hospital, Seoul, South Korea, dDepartment of Emergency Medicine, Seoul National University, Seoul, South Korea, eNational Traffic Injury Rehabilitation Hospital, Yangpyeong, South Korea, fInstitute on Aging, Seoul National University, Seoul, South Korea, gDepartment of Laboratory Medicine, Seoul National University Hospital, Seoul, South Korea, hLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea, iBrain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, South Korea, jKU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul, South Korea
ABSTRACT
Mild traumatic brain injury (mTBI) is prevalent in younger population with high level of physical activities that have been linked to increased rate of incidences. Although mTBI is rarely resulted in death, unidentified and prolonged mTBI, as a stealth pathology, may cause life-long disability. Recently developed biomarker coupled with enzyme-linked immunosorbent assay (ELISA) is sensitive but lack of multiplex and time-consuming procedure prevents it from using at the emergency department. Here, we report a new improved immunoassay-based mTBI diagnostic method that is operated by multiplexing UCH-L1 and GFAP with high selectivity and sensitivity in clinical serum tests within 50 min. The Versatile, Easy, and User-friendly IVD System (VEUS) is designed to enable multiplex detection of target proteins with a low limit of detection (i.e., < 1 pg/mL) by conjugating individual antibodies to various length of rod-shaped magnetic beads. The VEUS possesses four core technologies enabling entirely automated rapid diagnostics: 1) multiplex enabling highly magnetizable rod-shaped paramagnetic particles (RSMPs) through length differences, 2) fast well-to-well handling of cartridge for reactions and washing, 3) a unique optical module for highly sensitive imaging under a larger field of view, and 4) software assistance for accurate and high-throughput fluorescence decoding and analysis. The system may contribute to an independent and a precise diagnosis of mTBI which is common in the field of emergency department and then devastating serious after effects due to the loss of diagnosis.
194 Subjective experiences of individuals with acquired brain injury derived from interacting with gamified rehabilitation exercises in highly ecological virtual reality environments
Ángela Méndezb, Adrián Borregoa, María Dolores Navarrob, Carolina Colomerb, Joan Ferrib, Enrique Noéb, Roberto Llorensa
aNeurorehabilitation and Brain Research Group, Universitat Politècnica de València, Valencia, Spain, bIRENEA. Instituto de Rehabilitación Neurológica, Fundación Vithas, Valencia, Spain
ABSTRACT
Introduction: Balance, mobility and upper limb impairments are frequent in those individuals who have suffered a brain injury. The rehabilitation of these skills is essential, since it is associated with a significant increase in autonomy. Interventions based on motor learning principles that are based on repetitive, intensive, task-oriented, and difficulty-adapted exercises have been shown to provide clinical improvements in brain-injured subjects, even long after injury. Virtual reality (VR) and video games have been proposed to overcome certain limitations of conventional rehabilitation approaches, providing customized exercises, augmented feedback and goal-oriented tasks that can potentially increase motivation and intensity and, finally, adherence to treatment. An increasing number of studies report promising results of using these systems to improve motor function after stroke. However, the performance in activities of daily living and self-dependence requires a complex and combined execution of motor and cognitive skills in real environments, usually very different and more challenging than those simulated in VR-based rehabilitation systems. Consequently, the transference of gains with these systems to real life might be limited. We have developed a VR system that enables the training of activities of daily living in highly ecological environments through gamified tasks that require the combined use of motor and cognitive skills. The simulated activities take place in virtual replicas of each individual’s home (those rooms where the task should be performed in the end), which is expected to maximize the transfer of the improvements promoted by the training in the virtual environment to the execution of the real task. The objective of this study was to investigate the subjective experience of a representative sample of individuals with brain injury while interacting with the system.
Methods: Twenty-five individuals (60% men) with acquired brain injury (36% with stroke, 44% traumatic brain injury, 20% other causes), with a mean age of 54.9 (16.3) years, and a mean time post-injury of 32.6 (64.8) months participated in the study. Participants interacted 4-minutes with each of 3 exercises of the system with 2-minute breaks between them. After the interaction, the participants completed 5 questionnaires about usability, motivation, presence, game flow and game experience.
Results: Participants reported the VR-based system as being usable and highly motivating but not excessively stressful. Additionally, participants felt being present in the virtual environment and experienced game flow during the interaction, and reported a successful game experience with high-perceived positive value of the exercises.
Conclusions: The interaction with gamified VR-based exercises in highly ecological environments provided a robust, motivating, realistic, engaging, and enjoyable experience to individuals with acquired brain injury.
Acknowledgments: This study was funded by Ministerio de Ciencia y Educación of Spain (RTC2019-006933-7) and by Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15).
195 Development of an automated pipeline for the analysis of [18 F]FDG-PET images in disorders of consciousness
Arianna Salaa,b, Andreas Schindelec, Nikita Beliyd, Claire Bernarde, Rajanikant Pandaa,b, Christophe Phillipsd, Mohamed Ali Bahrid, Roland Hustinxe, Steven Laureysa,b,f, Olivia Gosseriesa,b, Aurore Thibauta,b, Jitka Annena,b,d
aComa Science Group, GIGA-Consciousness, Université De Liège, Liege, Belgium, bCentre du Cerveau2, University Hospital of Liège, Liege, Belgium, cKlinik für Nuklearmedizin, Universitätsklinikum Augsburg, Augsburg, Germany, dGIGA CRC in-vivo imaging, University of Liège, Liege, Belgium, eMédecine nucléaire et imagerie oncologique, University Hospital of Liège, Liege, Belgium, fCERVO Brain Research Center, Laval University, Québec, Canada
ABSTRACT
Aim/Introduction: Alterations of brain glucose metabolism, as measured by 2-[18 F]fluoro-2-deoxy-D-glucose-Positron Emission Tomography ([18 F]FDG-PET), are a well-established observation in patients with disorders of consciousness (DoC) after severe brain injury. The degree of consciousness impairment is associated with decreased brain glucose metabolism, especially in the frontoparietal network. As behavioral signs of consciousness (or lack thereof) do not always reflect the level of residual -covert- consciousness, [18 F]FDG-PET provides direct insight into cerebral activity, complementing bedside examinations. Still, limited resources for neuroimage analyses hinders quantitative evaluation of [18 F]FDG-PET in clinical settings.
We provide an automated, fast, user-friendly, free-to-use analysis pipeline for [18 F]FDG-PET brain images in DoC patients.
Materials and Methods: The open-source (GPL2) Statistical Parametric Mapping pipeline written in MATLAB (freely available online on the GitHub platform: https://github.com/GIGA Consciousness/COFFEE_BREAK_FDGPET) for [18 F]FDG-PET analysis in DoC patients, is based on validated analytical procedures [1–3] routinely used at the Coma Science Group and Center du Cerveau2, Liège, Belgium.
Results: The pipeline takes in the patient’s [18 F]FDG-PET DICOM images. All pre-processing steps are performed automatically, following a stand-alone pipeline based on a DoC-specific template. The processed image is statistically compared to a reference group (33 healthy controls;19–70 years old; 18/15 males/females; freely available online on the EBRAINS platform: https://search.kg.ebrains.eu/instances/Dataset/68a61eab-7ba9-47cf-be78-b9addd64bb2f)), to:
(i) produce voxel-based maps of relative hypometabolism and preserved metabolism, based on standardized uptake value ratio (SUVr, with global mean scaling);
(ii) estimate the decrease in the patient’s global brain glucose metabolism, based on SUV;
(iii) provide summary statistics and graphical renderings to aid clinical interpretation.
Conclusions: This is the first automated pipeline for [18 F] FDG-PET analysis in DoC patients, allowing generation of ready-to-use statistics from DICOM images in 1–2 minutes. Further work is ongoing to include additional metrics [4].
References
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2. Thibaut A, Bruno MA, Chatelle C, Gosseries O, Vanhaudenhuyse A, Demertzi A, et al. Metabolic activity in external and internal awareness networks in severely brain-damaged patients. J Rehabil Med. 2012;44:487–494.
3. Thibaut A, Panda R, Annen J, Sanz L, Naccache L, Martial C, et al. Preservation of brain activity in unresponsive patients identifies MCS star. Ann Neurol. 2021.
4. Stender J, Mortensen KNN, Thibaut A, Darkner S, Laureys S, Gjedde A, et al. The Minimal Energetic Requirement of Sustained Awareness after Brain Injury. Curr Biol. 2016;26:1494–9.
196 Cognitive recovery following aneurysmal and angiographically negative subarachnoid hemorrhage (SAH)
Sara Khosdelazada, Lieke S. Jornaa, Sandra E. Rakersa, Ralf Koffijbergb, Rob J.M. Groenc, Anne M. Buunka,c, Jacoba M. Spikmana
aDepartment of Neurology, unit Neuropsychology, University Medical Center Groningen, Groningen, Netherlands, bDepartment of Medical Psychology, Medical Center Leeuwarden, Leeuwarden, Netherlands, cDepartment of Neurosurgery, University Medical Center Groningen, Groningen, Netherlands
ABSTRACT
Studies on recovery after a subarachnoid hemorrhage (SAH) usually investigate motor and other neurological outcomes only, using for example the modified Ranking Scale (mRS) or Glasgow Coma Scale (GCS). However, previous research has consistently found cognitive deficits in this patient group that often go undetected by the mRS and GCS. Although much research is devoted to examining these cognitive deficits, research on cognitive recovery after SAH is scarce and, up to now, has only been conducted in aneurysmal SAH (aSAH) patients. Moreover, the time course of recovery in previous research was up to a maximum of 15 months post-ictus. The current study is the first to longitudinally investigate whether early cognitive deficits recover in the chronic stage after SAH, separately for patients with aSAH and angiographically negative SAH (anSAH). Our sample consisted of 58 aSAH and 22 anSAH patients. Cognition was measured with validated and standardized neuropsychological tests across multiple domains, including memory, psychomotor speed, and executive functioning (EF). Recovery was investigated by comparing cognitive and psychological functioning between the subacute (±3 to ±6 months) and chronic stage (±2 to ±4 years) post ictus, using Student’s paired sample t-tests or Wilcoxon Signed Rank tests. Test performances below the 10th percentile, compared to age and education matched normative values as used in clinical practice, were considered to be impaired. The results showed significant improvements on two subtests measuring memory in aSAH patients, effect sizes were low to moderate. However, at the chronic stage post ictus, 67% of aSAH patients still showed memory impairments. On the contrary, anSAH patients had significantly lower scores on subtests measuring psychomotor speed at the chronic stage post ictus as compared to the subacute stage. Furthermore, at the chronic stage, 84% of aSAH patients and 86% of anSAH patients showed deviated performances on at least one subtest. The present findings show minimal recovery of cognitive functioning between the subacute and chronic stage in aSAH patients and no recovery in anSAH patients. This implies that measurement of cognition at the subacute stage post ictus is a reliable indication of functioning in the long term. Moreover, cognitive deficits are still present in a large percentage of patients in the chronic stage, which indicates that SAH results in persistent cognitive impairments. A timely investigation by means of a comprehensive neuropsychological examination is of great value for the identification of residual cognitive impairments post aSAH and anSAH and also to make patients aware of their deficits. For clinical practice, it may be beneficial to provide SAH patients with appropriate (psychoeducational) interventions.
197 Information of the coma recovery scale-revised that mostly contributes to predict recovery of consciousness. A machine learning analysis
Silvia Campagninic,d, Andrea Manninic, María Dolores Navarrob, Joan Ferrib, José Olayab, Belén Molinerb, Carolina Colomerb, Myrtha O’Valleb, Enrique Noéb, Roberto Llorensa
aNeurorehabilitation and Brain Research Group, Universitat Politècnica de València, Valencia, Spain, bIRENEA. Instituto de Rehabilitación Neurológica, Fundación Vithas, Valencia, Spain, cIRCCS Fondazione Don Carlo gnocchi onlus, Firenze, Italy, dThe Biorobotics Institute, Scuola superior Sant’Anna, Pisa, Italy
ABSTRACT
Introduction: The Coma Recovery Scale-Revised (CRS-R) is the most recommended bedside instrument for the diagnosis of individuals with a Disorder of Consciousness (DoC) after a brain injury and its use is increasing in clinical practice worldwide. However, despite the amount of information gathered by the therapists to fill in the instrument, it is commonly interpreted using (only) its total score. It is therefore unknown whether all this information can be exploited to improve the current prognosis of this population. A few interesting attempts have proposed and investigated alternative measures derived from the CRS-R. Recent advances in Machine Learning (ML) have enabled new analysis techniques to be applied to biomedical data, which could potentially lead to more robust and generalizable results than conventional analyses, but their application to information derived from the CRS-R is anecdotal. This paper aims to determine which information derived from the CRS-R administered at admission to a long-term neurorehabilitation program can provide a better prediction of the emergence of DoC at discharge.
Methods: A cohort of 171 individuals admitted between 2004 and 2021 in 3 neurorehabilitation facilities of the same network was retrospectively enrolled. The inclusion criteria were having i) vascular, anoxic or traumatic etiology, iii) an age ≥ 16 years old, and iii) a minimum stay of 3 months in the neurorehabilitation program. According to previous studies, the confounders considered in the ML analyses were age, sex, etiology, lesion lateralization, time post-onset, presence of epilepsy (early or late seizures), and Disability Rating Scale, all of them at admission. The outcome of the ML analyses was the emergence or non-emergence at discharge. The selected measures derived from the CRS-R for the ML analyses were the total score, the clinical condition, the scores in all subscales, the CRS+, the CRS-R Modified Score, the CRS-R Index, and the Consciousness Domain Index. Seven different ML models were cross-validated for the same outcome using all the confounders described above and only one measure derived from the CRS-R for each model as predictors.
Results: The models that considered the total score and the scores in the subscales showed the best overall performances (accuracies = 0.78), followed by the model with the Consciousness Domain Index, which also showed the best detection of emergence (F1-score = 0.57). The worst performances were observed in the models that included the CRS-R Modified Score and CRS-R Index (accuracies = 0.73, and F1-scores = 0.38 and 0.36, respectively).
Conclusions: The total score and the scores in the subscales can be the most appropriate measures for the accurate prediction of the emergence of individuals with DoC.
Acknowledgments: This study was supported by the European Commission (EU-H2020-MSCA–RISE–778234) and the Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15).
198 Participation in a Norwegian intervention study with chronic traumatic brain injury survivors -translation and measurement properties of the Norwegian PART-O
Solveig L. Haugera,b, Ida M. H. Borgenc, Silje C. R. Furec,d, Marit V. Forslundc, Ingerid Kleffelgårdc, Nada Andelicc,d, Marianne Løvstada,b, Cecilie Røec,e
aDepartment of Reseach, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, bDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, cDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, dCenter for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, eInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
ABSTRACT
Objectives: The Participation Assessment with Recombined Tools-Objective (PART-O-17) measures participation and is recommended by the Common Data Elements. The 17 item PART-O has been translated into Norwegian, but the properties of the Norwegian version are unknown. The aim of this study was to 1) evaluate how Norwegian community dwelling persons living with traumatic brain injury (TBI) in the chronic phase report participation, and 2) explore the measurement properties of PART-O in the Norwegian setting.
Methods: The PART-O was translated to Norwegian in a forward/backward translation consensus-based process. Home-dwelling persons with verified clinical TBI and persistent symptoms, included in an intervention study from 2018 throughout 2020, rated their participation using the PART-O. Items were scored on a 6- (13 items), 5- (1 item) or 2-point scale (3 items). Date of assessment with respect to the Covid pandemic was noted. Descriptive statistics, correlation and Rasch analysis (RUMM 2030) of the PART-O and its three subscales (Productivity, Being Out and About, and Social Relations) were conducted.
Results: We included 120 patients, with a mean age of 45.2 (SD 14.4) years. Mean Glasgow Coma Scale score at injury was 9.3 (SD 4.3), 71% were males, and time since injury ranged from 2–24 years. Mean score on the PART-O total was 1.9 (SD 0.5). Highest degree of participation was found on the Social Relation subscale 2.6 (SD 0.9), followed by Productivity subscale 1.5 (SD 0.9) and Being Out and About subscale 1.5 (SD 0.5). Distribution of scores were highly skewed for several items: 47% reporting zero working hours, 89% no school/study, 83% never being spectators at sports events, and 91% never attending religious or spiritual services. Eating outside home (74% less than four times/month) and going to the cinema (83% zero times/month) were also skewed toward low attendance. 82% responded before the Covid pandemic. The only item associated with assessment under the pandemic was use of internet for communication (rho = 0.54, p < 0.001), which increased. Eleven of the items needed rescoring, with four or less valid scoring options for the items instead of the original 6-point scoring. Rasch analysis after rescoring indicated that the PART-O fitted the Rasch model (χ2 = 43.42, p = 0.13). Of the three PART-O subscales, only the Social Relation and Productivity subscales fitted the Rasch model. However, results showed low power for the 3-item Productivity scale.
Discussion: Several highly skewed PART-O item scores were found in a Norwegian TBI sample, and the low participation rates were not explained by the Covid pandemic. The analyses confirmed a valid construct of participation for the Social Relation and Productivity subscales, whereas the Being Out and About subscale was less suited for a Norwegian TBI population. In summary, the PART-O needs further adaptation before comparing scores across countries.
199 Reliability and validity of the spanish adaptation of the functional independence measure plus functional assessment measure in stroke
Dr. Roberto Llorensa, Enrique Noéb, María Dolores Navarrob, Carolina Colomerb, Belén Molinerb, Clara Rodríguezb, Patricia Ugartb, Myrtha O’Valleb, Carmen Blázquezb, Pablo Villarinob, Desiré Amorósb, Silvia Cerezob, Joan Ferrib
aNeurorehabilitation and Brain Research Group, Universitat Politècnica de València, Valencia, Spain, bIRENEA. Instituto de Rehabilitación Neurológica, Fundación Vithas, Valencia, Spain
ABSTRACT
Introduction: The Functional Independence Measure (FIM), either administered individually or in combination with the Functional Assessment Measure (FAM), is one of the most widespread and recommended measures of disability, and most adapted to various languages. However, the reliability and validity of most of them, including the adaptation to Spanish, is unknown. The objective of this study was to determine the internal consistency, the inter-rater reliability and the convergent validity of a Spanish adaptation of the FIM+FAM.
Material and Methods: A total of 122 subjects with ischemic (N = 77) or hemorrhagic (N = 45) stroke, 39 women (32%) and 83 men (68%), with a mean age of 63.7 ± 14.3 years, and a mean time since the injury of 126.7 ± 174.4 days, were assessed with the adapted version to Spanish of the FIM+FAM and, additionally, with a battery of disability, mobility and cognition scales.
Results: The internal consistency of the translated version of the FIM+FAM, evaluated with Cronbach’s α, was very high (α = 0.973). The convergent validity of each subscale of the FIM+FAM with the different clinical instruments, evaluated by correlation analyses, was consistent and showed greater correlation strength between those subscales and instruments that assessed related skills. The inter-rater reliability, evaluated with the intraclass correlation coefficient, was excellent for all the subscales (ICC>0.991).
Conclusions: The Spanish adaptation of the FIM+FAM proved to be a reliable and valid tool to assess disability in population with stroke.
Acknowledgments: This study was funded by Ministerio de Ciencia y Educación of Spain (RTC2019-006933-7) and by Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15).
201 Development of the intervention “get going after ConcussIoN lite” (GAIN Lite) to reduce impairing post-concussional mild-to-moderate symptoms in adults: a non-randomized feasibility study
Sedsel Kristine Stage Pedersena, Mille Møller Thatsuma, Erhard Trillingsgaard Næss-Smitha,b, Lene Odgårda, Hanne Pallesena,b, Jørgen Feldbæk Nielsena,b, Noah Silverbergc, Iris Brunnera,b
aHammel Neurorehabilitation Center and University Research Clinic, Hammel, Denmark, bDepartment of Clinical Medicine at Aarhus University, Aarhus N, Denmark, cDepartment of Psychology, University of British Columbia, Vancouver, Canada
ABSTRACT
Background: Concussion, the mildest form of traumatic brain injury, is an important public health concern due to high healthcare costs because of post-concussion symptoms (PCS). The majority of affected individuals apparently recover from the concussion within 1–3 months, but up to a third develop persistent PCS lasting more than 3 months. PCS is associated with substantial ongoing disability and distress. Recognition is growing that PCS is best understood in terms of an interaction between biological, psychological and social factors. However, evidence for effective non-pharmacological treatment strategies is scarce. Brief tele-health interventions to prevent prolonged PCS have demonstrated promising results and are likely to be cost-effective. Recently, the effect of a novel intervention “Get going After concussIoN” (GAIN) for people with persistent severe PCS was examined, showing a significantly larger reduction in PCS in the intervention group 3 months post-intervention than in the control group. Adapting the treatment principles and developing a down-scaled version of GAIN for adults with persistent mild to moderate PCS is hence warranted.
Objective: To present the adaption and development processes of the intervention GAIN Lite; a digital intervention aimed at preventing cornification among adults with mild to moderate post-concessional symptoms.
Design: An iterative method based on the UK Medical Research Council’s framework for developing and evaluating complex interventions combined with guidance for adapting interventions to new contexts guided the overall process. The approach was target-population based.
Setting: GAIN Lite was developed in the Central Denmark Region and led by Hammel Neurorehabilitation Center and University Research Clinic in collaboration with a broad range of stakeholders; people having had a concussion; therapists delivering the intervention; researchers and various experts, namely the people behind the original GAIN study.
Results: The intervention has two major components: 1) six e-learning videos with a total duration of 50 minutes, and 2) up to four individual online sessions with a maximum duration of 60 minutes each.
Conclusions: A systematic approach has been applied in the development process. Transparency in the development processes of GAIN Lite may improve prerequisites for research and clinical implementation. The GAIN Lite intervention will be developed over a two-year period, from January 2021 to January 2023, before implementation into a randomized clinical trial.
202 Training for police staff in recognizing and responding to traumatic brain injury
Huw Williamsa, Hope Kenta
aUniversity of Exeter, Exeter, United Kingdom
ABSTRACT
Introduction: This collaborative project between the University of Exeter and Devon & Cornwall (D&C) Police aimed to provide staff with skills and knowledge to screen for TBI and support offenders with TBI in rehabilitative goals. We also aimed to establish the prevalence and severity of brain injury and determine whether TBI was associated with increased likelihood of additional identified needs that are associated with crime and desistence, including substance use problems, housing problems, physical health problems, mental health problems, educational difficulties, being a victim of domestic violence, or having other identified needs. This project was delivered across two police teams – Pathfinder, and Integrated Offender Management (IOM), in the context of a public health approach to crime reduction. Pathfinder is a voluntary deferred caution and charge scheme in which eligible offenders can engage with key workers who deliver psycho-social interventions, or signpost to other relevant services. In IOM, the most persistent and problematic offenders are identified and managed jointly by partner agencies working together.
Method: In the qualitative phase of the project, police staff attended three workshops to learn about TBI and associated behavioral, cognitive, and emotional problems. Instruction was provided about the use of the Brain Injury Screening Index (BISI), a well validated tool developed within the criminal justice system by The Disabilities Trust Foundation. 16 staff members then volunteered to take part in one-to-one interviews to share more about their experiences of using the BISI and give feedback on the screening tool. In the quantitative phase, the BISI was then used to screen offenders in contact with the pathfinder and IOM teams for a history of TBI, and these data were shared with the research team.
Results: Data were collected in the IOM (N = 19) and Pathfinder (N = 72) teams. 59.3% of those screened reported a lifetime TBI. The mean BISI score for IOM was 9.58, and for pathfinder was 4.31. The number of vulnerability flags an individual has was significantly predicted by higher BISI Index Scores. Staff were generally receptive to the use of the BISI and found that it helped them to understand the people they were working with, creating an awareness of the lifetime TBI that people in contact with the pathfinder and IOM teams have had which may impact current ability to engage with the programmes.
Implications: These pilot results indicate that the BISI is a useful screening tool for police teams working with populations with complex needs, and that an increased awareness of TBI could help police staff to feel confident identifying and working with neurodiverse populations. Screening for TBI is valuable and can help staff to understand why an individual may be disengaged or may have difficulty understanding instructions and requirements.
204 Person-centered rehabilitation goals of military service members and veterans with mild traumatic brain injury and co-occurring psychological conditions
Tracey Wallacea, April Hodgea, Tim Moranb, Katherine McCauleya, Lyndsey Edelmana, Russell Gorea
aShepherd Center, Atlanta, USA, bEmory University, Atlanta, USA
ABSTRACT
Person-centered care approaches to brain injury rehabilitation have been demonstrated to facilitate optimization of care and achievement of meaningful outcomes, and person-centered goal setting is a critical component of this care. The use of person-centered goals in moderate-severe brain injury is demonstrated to encourage helpful behaviors, foster patient engagement, and correlate with improved outcomes. Less is known regarding the content of person-centered goals and relative likelihood of goal attainment in brain injury subpopulations. In this retrospective chart review study, person-centered goals were extracted from medical records of 146 military service members and Veterans (SM/Vs) with a history of mild traumatic brain injury (mTBI) occurring at least 6 months prior as well as co-occurring psychological conditions, most commonly Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD), who participated in an intensive outpatient rehabilitation program (IOP). Each record contained one to three person-centered goals, totaling 281 goals. Goals were identified by the patient and collaboratively scaled with an interdisciplinary treatment team using goal attainment scaling. Goal attainment measurements were recorded at IOP discharge and again at six, nine, and twelve-months post-discharge. Two members of the study team first separately reviewed the goals and then collaboratively identified 10 thematic goal categories. They then separately re-reviewed and categorized each goal, resulting in 98% agreement. Discrepancies were resolved through discussion, resulting in 100% agreement. Goals were categorized as Active in Community (22.3%), Family Relations (14.6%), Behavioral/Emotional (13.8%), Independence (11.9%), Work (9.2%), Fitness (8.8%), Active at Home (6.2%) School (5.8%), Cognitive Limitation (4.6%), and Other (2.7%). Of the 281 goals, 252 were met or exceeded by program discharge. Severity of PTSD and MDD symptoms at program admission did not predict goal categories. A mixed-effects model (adjusted for demographics) showed that Active at Home goals (Odds Ratio (OR) = 4.2, 95% Confidence Interval (CI): 1.8–10) were more likely to achieve greater goal attainment on average across measurement timepoints, whereas Fitness (OR = 0.4, 95% CI: 0.2–0.98) and School (OR = 0.2, 95% CI: 0.1–0.6) were less likely. Importantly, a main effect of time determined that goal attainment tended to increase over time post-discharge (OR = 1.06, 95% CI: 1.03–1.06). A significant Category-by-Time interaction revealed that the exception to this trend was Fitness-related goals which showed a non-significant decrease in attainment over time (OR = 0.98, 95% CI: 0.9–1.1). Military SM/Vs with a history of mTBI and co-occurring psychological conditions identify a variety of person-centered goals for which they may demonstrate attainment post-IOP. Person-centered goal attainment may serve as a useful outcome measure in this population. Future studies should further investigate barriers and facilitators to person-centered goal attainment among brain injury subpopulation including factors influencing goal content and relative likelihood of goal attainment.
205 A survey of healthcare perceptions across the recovery continuum
Jerry Hoepnera, Louise Keeganb
aUniversity of Wisconsin – Eau Claire, Eau Claire, USA, bMoravian University, Bethlehem, USA
ABSTRACT
Background: Perceptions of healthcare experiences influence healthcare outcomes. Previous investigations of healthcare perceptions of individuals with TBI were retrospective and excluded some severities or recovery phases (Andelic et al., 2014; Manskow et al., 2018). Acute care perceptions are more positive, whereas transitions, discharges, and follow-up management in the subacute to chronic phases of recovery are more negative (Turner et al., 2008). Individuals with moderate to severe TBIs have good access to acute care but less access to specialized services after discharge, including a lack of services in the chronic phase (O’Callaghan et al., 2010). Poor communication, limited or no participation in discharge/transition planning, disorganized arrangements for transitions, and insufficient treatment were consistently identified by patients and family members (Piccena et al., 2016). A lack of education about TBI consequences and dependence on family members further contributes to these negative perceptions (Manskow et al., 2018). Difficulties in the chronic phase are likely exacerbated by these poor transitions and a lack of follow-up care (Lefebvre et al., 2008).
Purpose: To examine health care perceptions of individuals with TBI across severity levels and the recovery continuum.
Method: The two-part investigation included a survey and follow-up interview. Participants, who self-reported as having a TBI were recruited from community based and online TBI support groups and invited to participate in the initial survey. Eighty-seven surveys were completed, including 64 from participants who met the inclusion criteria (18 years old, > one year post onset, history of only one TBI, no neurological or psychiatric diagnoses prior to TBI). Forty (62.5%) respondents provided contact information and 18 individuals with varying severities of injury (mild, moderate, and severe) were randomly selected for a follow up interview. Interviews were analyzed using an interpretative phenomenological analysis (IPA) approach, as well as linguistic appraisal analysis.
Results: Quantitative results revealed that participants were less satisfied with the services received in long term, chronic care situations than acute or rehabilitation settings. Additionally, therapy providers (occupational, speech and physical) were rated consistently higher than nurses or physicians as related to care and communication about their care. Qualitative IPA of the interview data highlighted differences across severity levels. Three core themes common to all severities were identified: ‘frustrations with providers,’ ‘lack of supports in the chronic phase of recovery,’ and ‘finding supports is crucial.’ Appraisal analysis provided insight into how individuals evaluated their experiences in light of their identity and personal perspectives. Both qualitative analyses revealed that individuals with mild TBI expressed the most discontent with services. All participants were most satisfied with acute care and least satisfied with chronic phase supports. This presentation will discuss this data in light of current recommendations for best practices in healthcare provision.
206 Barriers to accessing rehabilitation services after traumatic brain injury
Anna Tobina, Rebecca Dennissa
aUniversity Of Sheffield, Sheffield, United Kingdom
ABSTRACT
Objective: This study aimed to investigate the gap between patient need and barriers to accessing rehabilitation services following traumatic brain injury (TBI) to investigate where this disconnect is occurring by talking to affected individuals.
Background: Approximately one million people a year attend hospital with a head injury in the UK, leaving a significant proportion of these people with deficits in processing speed, memory, executive function and social cognition (Ponsford et al., 2014). Appropriate cognitive and physical rehabilitation following head injury is included within the NICE guidelines for head injury (NICE 2022), however previous research has indicated that some individuals are unable to access the rehabilitation they require. Identifying the gap between need and access to rehabilitation is thus a crucial first step in minimizing the barriers and improving the quality of life of people who have experienced a head injury.
Design/Methods: Data from 7 people with TBI (mean age = 48.7 years, SD = 7.6; 57.1% male) was obtained through semi-structured interviews via video conferencing. The interview gathered information about the participants’ brain injury and their experiences accessing rehabilitation services.
Results: Codes from the data were generated through an inductive analysis and a 6-phase method (Braun and Clarke, 2006) which translated into two main themes; adaption to life post-injury and external factors affecting rehabilitation. External factors affecting rehabilitation included sub themes of emotions experienced, not fitting in and reassurance about their symptoms. The themes and the subthemes described the participants perspective of their experience of rehabilitation following TBI and their opinion on how rehabilitation could be adapted to allow them to gain maximum benefit from the service. Participants frequently mentioned feeling a lack of support, often due to a lack of services together with unknowledgeable health care professionals. These impacted participants work life contributing to ongoing financial and emotional difficulties.
Conclusion: Participants found a significant gap between their need for rehabilitation and ability to access the services required. Many participants proposed support groups to connect them with other people who have had similar experiences to help validate their own feelings.
207 Intact memory benefit following disfluent speech in adults with moderate-severe traumatic brain injury
Evgeniia Diacheka, Sarah Brown-Schmidta, Melissa Duffb
aVanderbilt University, Nashville, USA, bVanderbilt University Medical Center, Nashville, USA
ABSTRACT
Traumatic brain injury (TBI) is associated with a range of cognitive-communicative deficits. While individuals with moderate-severe TBI often perform well on standardized tests of language, the cognitive-communicative deficits in this population include disruptions in memory and everyday communicative interactions. This discrepancy highlights the need to provide a detailed understanding of the mechanisms involved in language use that might support successful communication or be targeted in the presence of cognitive-communication deficits. The present research study examines memory for spoken language, and the features of speech that modulate memory for words that were said. In particular, we focus on a common feature of speech, disfluency, which is an interruption to the normal flow of speech due to pausing, repetition of words, and lexical disfluencies such as um and uh, among others. Disfluency shapes both language comprehension and production. Rather than a nuisance which is ignored by the language processing system, disfluency guides language understanding. Disfluency also orients attention, shaping long-term memories of discourse. Despite the ubiquitous presence of disfluency in everyday language use and the beneficial effects on memory, disfluencies are typically removed from or ignored in experimental studies of language use in TBI. Thus, little is known about how individuals with brain injury process disfluencies or if they receive the same memory benefits as neurotypical participants. To fill this gap in the literature, we asked 53 (23 female, 30 male) participants with adult onset moderate-severe TBI and 53 demographically matched neurotypical comparison participants to listen to a series of sentences, some of which contained different types of disfluencies (e.g., filler, pause, repetition). A subsequent memory test probed memory for critical words in the sentences. Participants with TBI correctly recognized the spoken words at a similar rate compared to neurotypical comparison participants. Critically, participants with TBI also exhibited a robust memory boost for words preceded by disfluency, suggesting that the attentional orienting mechanism which is responsible for the boost is intact following TBI. Thus, not only are individuals with moderate-severe TBI sensitive to attentional orienting cues in speech, but, like neurotypical peers, the presence of a disfluency improved memory for what was said. These findings are part of a growing body of work pointing to spared cue processing (e.g., eye-gaze) in individuals with TBI when the cues are experimentally isolated. Future studies should examine the duration of the observed memory boost and if these findings extend to face-to-face interactions where multiple social and communicative cues are present. This study also highlights the value of studying language use as it actually occurs, disfluencies and all, which may improve our ability to translate findings to everyday communicative contexts.
208 Developing a competency framework for social workers who work with adults who may have an acquired brain injury
Philomena Butlera, Danielle Manningb
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland, bAcquired Brain Injury Ireland, Dublin, Ireland
ABSTRACT
In Ireland, approximately 9000 to 11000 people sustain a traumatic brain injury annually, and 8000 are treated for a stroke (www.headway.ie, ABI Ireland annual report 2018). Social workers in Ireland work with children and adults with acquired brain injuries (ABI) and other neurological conditions in hospital and community settings. Working in acquired brain injury rehabilitation gives social workers a unique opportunity to work with clients and families who are dealing with a life altering condition with a high degree of uncertainty and ambiguous loss. Social workers work with clients to support their adjustment to the newly acquired injury, but they also work with families, as the impact on family members can be varied and multi-layered and a ‘family affair’ (Simpson et al. 2016). They are guided by the CORU Code of Professional Conduct and Ethics and use their social work skills and training to provide a service to these clients and families. However, there are specific areas of knowledge and expertise required for those working with adults with neurological conditions, as many of the symptoms of ABI are invisible, and specific knowledge and skills are required to recognize the challenges and needs of service users. With this in mind, and informed by the World Health Organization Rehabilitation Competency Framework 2020, a working group of social workers are developing a competency framework, which should guide social workers in this area. It is also envisaged that the framework could provide a training opportunity for those social workers who come into contact with adults with ABI in other settings, such as child protection, disability services, housing services and so on. This framework will highlight the standards expected of social workers working with adults with neurological conditions in both inpatient and community settings and provide an opportunity to promote excellence in the social work service with this client group.
209 A systematic review of treatments of post-concussion symptoms
Philippe Azouvia, Camille heslota, Valerie Perdrieaua, Ms Margaux Foussarda, Clemence Lefevrea, Melanie Cogneb
aUniversity of Versailles – Saint Quentin, Garches, France, bRehabilitation Unit, Rennes University Hospital, Rennes, France
ABSTRACT
Background: About 10–20% of patients who sustained a mild Traumatic Brain Injury (mTBI) show persistent post-concussion symptoms (PCS). This review aims at summarizing the level of evidence of interventions for PCS.
Methods: Following the PRISMA guidelines, we conducted a systematic review regarding interventions for PCS post-mTBI until August 2021, using the Medline, Cochrane and Embase databases. Inclusion criteria were the following: (1) intervention focusing on PCS after mTBI (2) presence of a control group, (3) adult patients (≥18 y.o). Quality assessment was made using the Incog recommendation level and the risk of bias assessed using the Cochrane risk-of-bias tool, revised.
Results: We first selected 121 full-text articles. Finally, 55 studies were retained, including 35 that obtained the highest level of evidence. The risk of bias was high in 21 out of 55 studies Cognitive training, psycho-education, cognitive behavioral therapy, and graded return to physical activity demonstrated some effectiveness on persistent PCS. There is limited evidence of a beneficial effect of Methylphenidate. Oculomotor rehabilitation, light therapy and headache management using repetitive transcranial magnetic stimulation seem effective on somatic complaints and sleep disorders. The preventive effect of early (<3 months) interventions remains up for debate.
Discussion/conclusion. Despite its limitations, the results of the present review should encourage clinicians to propose a tailored treatment to patients, according to the type and severity of PCS, and could encourage further research.
210 Functional outcome and change in outcome in patients with moderate and severe traumatic brain injury – a 15-year prospective cohort study
Rabea Pantelatosa, Jonas Stenberga, Turid Follestadb, Oddrun Sandrødc, Anne Vika,d, Toril Skandsena,e
aDepartment of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, bThe Unit for Applied Clinical Research (AKF), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, cClinic of Anesthesia and Intensive Care, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway, dNeuroclinic, Department of Neurosurgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway, eClinic of Physical Medicine and Rehabilitation, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
ABSTRACT
Background: In a 15-year cohort of surviving patients with moderate and severe traumatic brain injury (TBI) from Central Norway, the aim was to report functional outcome at 12 months and to report the change in outcome from 6 to 12 months post-injury.
Material and Methods: All surviving patients aged ≥ 16 years admitted with moderate (Glasgow Coma Scale (GCS) score 9–13) or severe TBI (GCS score ≤ 8) to the regional trauma center in Central Norway between 01.10.2004 and 01.10.2019 were prospectively included. Functional outcome was measured with the Glasgow Outcome Scale Extended (GOSE): GOSE score 2 = vegetative state, 3–4 = severe disability, 5–6 = moderate disability, 7–8 = good recovery. Patients eligible for follow-up were interviewed with the GOSE at 6 and 12 months after the injury.
Results: Out of 538 surviving patients, 12-month functional outcome was recorded in 452 (84%) patients; 56% with moderate and 44% with severe TBI. Twelve months post-injury, 12% of patients with moderate TBI had severe disability, 25% moderate disability and 63% good recovery. Of patients with severe TBI, 26% had severe disability, 41% moderate disability and 33% good recovery. Two patients were in a persistent vegetative state 12 months after injury. From 6 to 12 months post-injury, 28% of patients with moderate and 32% of patients with severe TBI had an improvement; 6% of patients with moderate and 5% of patients with severe TBI had a deterioration in GOSE score.
Conclusion: Approximately 2/3 of patients with moderate and 1/3 of patients with severe TBI experienced good recovery within 12 months after the injury and only 2 patients were in a persistent vegetative state. More than 1/3 of patients with moderate or severe TBI had a change in functional outcome from 6 to 12 months, predominately an improvement in outcome. Therefore, endpoints extending 6 months in studies are crucial.
211 Prediction of outcome in severe traumatic brain injury – the value of pragmatic estimation of the duration of posttraumatic confusional state
Rabea Pantelatosa, Jonas Stenberga, Turid Follestadb, Oddrun Sandrødc, Anne Vika,d, Toril Skandsena,e
aDepartment of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, bThe Unit for Applied Clinical Research (AKF), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, cClinic of Anesthesia and Intensive Care, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway, dNeuroclinic, Department of Neurosurgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway, eClinic of Physical Medicine and Rehabilitation, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
ABSTRACT
Background: In a 15-year cohort of surviving patients with severe traumatic brain injury (TBI) from Central Norway, the aim was to study if adding the duration of posttraumatic confusional state (PTCS) to a prognostic model would improve outcome prediction.
Material and Methods: All surviving patients aged ≥ 16 years admitted with severe TBI (Glasgow Coma Scale score (GCS) ≤ 8) to the regional trauma center in Central Norway between 01.10.2004 and 01.10.2019 were prospectively included in this study. Outcome was measured with the Glasgow Outcome Scale Extended (GOSE) 12 months post-injury: GOSE score 2 = vegetative state, 3–4 = severe disability, 5–6 = moderate disability, 7–8 = good recovery. Duration of PTCS was estimated retrospectively by evaluation of confusion, into one-week intervals, by review of hospital medical records. Uni- and multivariable binary logistic regression was used to test two prognostic models, with and without PTCS duration. Age, GCS score, and Rotterdam CT score were included as continuous variables; sex and PTCS duration (0–7, 8–28, more than 28 days) as categorical variables. The GOSE score was dichotomized into unfavorable (2–5) or favorable (6–8) outcome.
Results: Out of 235 surviving patients, 151 patients (64%) had a valid GOSE score 12 months after injury and an estimated PTCS duration. All patients with PTCS duration ≤ 28 days had a GOSE score greater than 4, and 79% had a favorable outcome. Of patients with PTCS duration more than 28 days, 21% had a favorable and 79% had an unfavorable outcome. In the multivariable binary logistic regression model without PTCS duration included, higher age (OR 1.03, 95% CI 1.00–1.05, p < 0.038) and a higher Rotterdam CT score (OR 1.65, 95% CI 1.15–2.37, p < 0.007) were significantly associated with unfavorable outcome (Nagelkerke R2 0.232, Akakike’s Information Criteria (AIC) 147.2, Bayesian Information Criteria (BIC) 160.9). When PTCS duration was included in the model, only longer PTCS duration (reference category: more than 28 days, 0–7 days: OR 0.08, 95% CI 0.02–0.30, p < 0.001, 8–28 days: OR 0.07, 95% CI 0.02–0.21, p < 0.001) was significantly associated with unfavorable outcome, and the model was better than without PTCS duration according to estimators of “goodness of fit” (Nagelkerke R2 0.495, AIC 119.5, BIC 138.8).
Conclusion: All patients with severe TBI with PTCS duration ≤ 28 days were independent in activities in daily life 12 months post-injury. Applying a pragmatic, retrospective estimation of PTCS duration could strongly improve performance of a prognostic model of severe TBI. PTCS duration outperformed age, sex, GCS score and Rotterdam CT score as prognostic variables.
213 Effects of a goal-oriented and home-based intervention in the chronic phase of traumatic brain injury
Ida M. H. Borgena,b, Marianne Løvstadb,c, Solveig L. Haugerb,c, Marit V. Forslunda, Ingerid Kleffelgårda, Cecilie Røea,d,e
aDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, bDepartment of Research, Sunnaas Rehabilitation Hospital, Nesoddtangen, Norway, cDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, dCenter for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, eInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
ABSTRACT
Background: There is a need for high quality, methodologically rigorous trials that evaluate community-based treatment options for traumatic brain injury (TBI) in the chronic phase. Sequelae after TBI are highly heterogeneous, thus there is a need to tailor rehabilitation interventions to meet the specific need of each patient.
Objectives: To evaluate the effect of a goal-oriented and home-based rehabilitation intervention in the chronic phase of traumatic brain injury.
Methods: Parallel two-group randomized controlled trial conducted in South-Eastern Norway. Pretest at baseline (T1), follow-up immediately post-intervention (4–5 months; T2) and at 12 months post-inclusion (T3). 120 participants were randomized 1:1 to treatment (n = 60) or control group (n = 60). Inclusion criteria were a TBI diagnosis with radiologically verified intracranial abnormalities, age 18–72 years, and time since injury ≥ 2 years. Participants had to be experiencing ongoing TBI-related cognitive, emotional, or physical problems, or difficulties with participation in activities with family, friends, or in the community. The intervention was individualized, goal-oriented, and delivered in-home or by videoconference, with eight intervention sessions over a 4-month period. Main elements were (i) identification of subjectively reported problem areas (Target Outcomes), (ii) establishment of SMART-goals and Goal Attainment Scaling, and (iii) development of an action plan with evidence-based strategies to achieve goals and mitigate symptoms. The control group received standard care in their municipalities. The primary outcome areas were health-related quality of life (HrQoL) and participation (The Quality Of Life after Brain Injury-Overall Scale; QOLIBRI-OS and Participation And Recombined Tools-Objective; PART-O). EuroQOL-5 Dimensions (EQ-5D) and Target Outcomes were included as secondary outcomes along with post-concussive symptoms (Rivermead Post-concussive Questionnaire), anxiety (Generalized Anxiety Disorder 7-item scale), depression (Patient Health Questionnaire 9-item), and functional competency (Patient Competency Rating Scale). Linear mixed models were used to evaluate time x group effects between T1-T3.
Results: Although the two primary outcomes did not differ statistically significantly between-groups, the intervention group displayed within-group improvement for QOLIBRI-OS (p = 0.037) and a significant between-group effect for the EQ-5D (p = 0.043) at T3. The intervention group further displayed significant improvement on Target Outcomes (p = 0.003) at T2 and lower rates of post-concussive symptoms (p = 0.043) and anxiety-related symptoms (p = 0.024) at T3, compared to the control group. All the secondary outcomes showed a significant within-group effect in the intervention group in the direction of improvement.
Conclusions: This intervention showed promise as a potential treatment option for a broad range of problem profiles found in the chronic phase of TBI. The overall improvements seen in the intervention group were not associated with improved participation, which could in part suggest that the PART-O might not have been sensitive to change in this population. The intervention might prove relevant for other acquired brain injuries, but more research is needed.
214 Longitudinal assessment of quality of life for brain injury survivors in post-rehabilitation programming
Cara Bridgmana, Paula Castellanosa, Andres Escobara, Jennifer Mozolica, Erica Rawlsb, Cristina Reitz-Kruegera, Kenia Romeroa
aWarren Wilson College, Asheville, USA, bHinds’ Feet Farm, Asheville, USA
ABSTRACT
Objective: Many people who sustain a brain injury will experience long-term effects in a variety of domains. Thus, there is a great need for post-rehabilitation approaches that can support quality of life in individuals affected by brain injury over extended periods. This research aims to use longitudinal data from participants in a member-driven program focused on holistic health and wellness and community reintegration to explore how quality of life changes over time for those living with ABI.
Method: Participants (n = 139) were members at two program locations where individuals regularly took part in a variety of on-site and community-based activities aimed at promoting engagement and connection. Members actively participated in choosing, structuring, and leading programming which included activities like art, cooking, writing, financial literacy, games, visits to parks and theaters, and volunteering. Program staff at both locations administered the Quality of Life after Brain Injury scale (QOLIBRI) on a quarterly basis to program members for a period of eight years. The QOLIBRI is a 37-item questionnaire that assesses health-related quality of life in six different domains: Cognition, Self, Autonomy & Daily Life, Social Relationships, Emotions, and Physical Problems. Each domain subscale and total composite score can range from zero to 100.
Results: Mean length of program participation for continuing members was three years (range = 0.5–7.0 years). On average, composite QOLIBRI scores were stable over time (m = 69.1, SD = 6.8; Δm = 2.0, ΔSD = 14.7). Quality of life measured in the subscale domains also remained steady with slightly positive trends during the study period (Cog Δm = 1.8, Self Δm = 1.8, ADL Δm = 3.1, Soc Δm = 0.1, Emo Δm = 3.0, Phys Δm = 2.7).
Conclusions: Member-driven programs that promote engagement and community re-integration can support long-term maintenance of quality of life for individuals with brain injury. More research is needed to explore how variations in programming might impact quality of life in various domains.
215 Opportunities and challenges in longitudinal assessment of quality of life after brain injury
Cara Bridgmana, Paula Castellanosa, Andres Escobara, Jennifer Mozolica, Erica Rawlsb, Cristina Reitz-Kruegera, Kenia Romeroa
aWarren Wilson College, Asheville, USA, bHinds’ Feet Farm, Asheville, USA
ABSTRACT
Background: Subjective assessments in individuals who have sustained a brain injury indicate that a wide variety of personal, social, and physical factors can influence quality of life. Here we explore opportunities and challenges in the longitudinal assessment of quality of life after brain injury among participants in a post-rehabilitation program focused on holistic health and wellness and community reintegration.
Method: Over a period of eight years, program staff at two locations administered the Quality of Life after Brain Injury scale (QOLIBRI) on a quarterly basis to program members. The QOLIBRI is a 37-item questionnaire that assesses health-related quality of life in six different domains: Cognition, Self, Autonomy & Daily Life, Social Relationships, Emotions, and Physical Problems. Participants in the program (n = 139) regularly took part in a variety of on-site and community-based activities aimed at promoting quality of life in all domains. Case studies and staff experiences with long-term participants were used to highlight opportunities and challenges for measuring quality of life for extended periods after brain injury.
Findings: Case studies suggested that subjective evaluation using the QOLIBRI may not adequately assess age-related changes, especially in the cognitive domain. Missing data, due to physical limitations, willingness to respond, and inconsistent program attendance also posed challenges to interpretation of QOLIBRI results.
Discussion: Longitudinal assessment of quality of life can provide valuable information for individuals with brain injuries and their caregivers. Adjustments to the measurement process, such as changes in assessment frequency, the addition of electronic forms, and the addition of program-specific items to the questionnaire may improve our understanding of how to best support quality of life after brain injury.
216 Global functional outcomes 3- and 6-months following pediatric concussion
Jacqueline Josee van Ierssela, Miriam Beauchampb,c, William Craigd, Quynh Doane, Jocelyn Gravelc,f, Roger Zemeka,g, Cherri Zhangh, Keith Owen Yeatesh,i, Andrée-Anne Ledouxa
aChildren’s Hospital of Eastern Ontario Research Institute, Ottawa, Canada, bDepartment of Psychology, Université de Montréal, Montréal, Canada, cCHU Sainte-Justine Hospital Research Center, Montréal, Canada, dDepartment of Pediatrics, Stollery Children’s Hospital and University of Alberta, Edmonton, Canada, eDepartment of Pediatrics, BC Children’s Hospital Research Institute and University of British Columbia, Vancouver, Canada, fDepartment of Pediatric Emergency Medicine, Université de Montréal, Montréal, Canada, gDepartments of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario and University of Ottawa, Ottawa, Canada, hAlberta Children’s Hospital Research Institute, Calgary, Canada, iDepartment of Psychology and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
ABSTRACT
Objectives: A substantial proportion of children will have persistent symptoms following concussion; however, long-term global functional outcomes are largely unknown. Our objectives were to: (1) characterize global functional outcomes in children with concussion compared with orthopedic injury (OI) 3- and 6-months postinjury; and (2) to examine whether the 5P clinical risk score, collected in the emergency department (ED), and parent-reported symptom status at 8-days postinjury are associated with global functional outcomes 3- and 6-months postinjury.
Methods: Planned secondary analysis of the multicentre prospective cohort study, Advancing Concussion Assessment in Pediatrics (A-CAP). Children aged 8.0–16.99 years with acute (< 48 hours) concussion or OI were recruited across 5 Pediatric Emergency Research Canada network EDs.
The primary outcome was global functional outcomes, categorized as good recovery (score of 8) versus poor recovery (score of ≤ 7), measured at 3- and 6-months post-injury using the Glasgow Outcome Scale-Extended Pediatric Version. The validated 5P clinical risk score was calculated from information collected in the ED. Parent-reported symptom status was assessed based on reliable change on the Health and Behavior Inventory 8-days post-injury. The association between recovery and injury type was assessed using χ2 tests. The ability of the 5P risk score and symptom status to predict 3- and 6-month global functional outcomes was evaluated using multivariable linear regression adjusted for sex, age, and parental education.
Results: 967 participants (concussion: N = 633; M[SD] age = 12.32(2.50) years; 60% male; OI: N = 334; M[SD] age = 12.58(2.22) years; 55% male) were included in the analysis. At 3-months, significantly fewer children with concussion (n = 371/471 [78.77%]) reported good recovery compared with children with OI (n = 169/180 [91.35%]; χ2[1] = 14.448; p < 0.001). Good recovery at 6-months was also reported in significantly fewer children with concussion (n = 369/449 [82.18%]) versus in those with OI (n = 170/189 [89.95%]; χ2[1] = 6.117; p = 0.013). In a multivariable model, the 5P risk score (ß = 0.210; 95%CI:0.031,0.390; p = .022) and symptom status at 8-days (ß = 0.979; 95%CI:0.462,1.496; p < 0.001) significantly predicted global functional outcomes at 3-months. At 6-months, the 5P risk score (ß = 0.206; 95%CI:0.014,0.398; p = 0.036) and symptom status (ß = 0.610; 95%CI:0.06,1.161; p = 0.03) also significantly predicted global functional recovery. No individual component of the 5P score was significantly associated with global functional outcome at 3-months; however, history of physician-diagnosed migraine (p = 0.035) and previous concussion with symptoms lasting longer than 1-week (p = 0.022) were associated with global functional outcome at 6-months.
Conclusion: Children with concussion have worse global functional outcomes than those with OI 3- and 6-months post-injury. An ED-collected clinical risk score and symptom status assessed 8-days post-injury predict functional recovery up to 6-months following concussion. These findings may help clinicians identify children with poor prognosis early after concussion and target management accordingly.
217 Assessment and evaluation of a crosswalk between the functional independence measure and the continuity assessment record and evaluation
Dave Mellicka
aCraig Hospital, Englewood, USA
ABSTRACT
Background: Assessment of functional outcome is a major initiative for facilities engaging in post-acute care. Unfortunately, across time, the various types of post-acute care facilities had developed measures to assess function independently of each other, making for comparisons of patients across facilities difficult. To rectify this difference, in 2005 the Centers for Medicare and Medicaid Services developed a comprehensive measure that all facilities were to use to assess function called the Continuity Assessment Record and Evaluation (CARE). However, because of the change in instruments, comparisons between the previous measures and the CARE necessitate a need for a crosswalk so that scores can be compared. This study focused on the creation and evaluation of a crosswalk between the motor subscale of the Functional Independence Measure (FIM), which had been used to assess function in inpatient rehabilitation facilities and the newer CARE tool.
Methods: An existing dataset of 982 persons who had sustained a moderate to severe traumatic brain injury and were assessed using both FIM and CARE at inpatient rehabilitation admission and discharge was utilized to create three crosswalks using various methodology (expert opinion, equipercentile and Rasch). The dataset was split into a training and validation dataset. Each crosswalk was evaluated using several criteria including, reduction in uncertainty, percent of each crosswalked score falling within a ½ standard deviation (SD) of the reference measure, population invariance, comparison of statistical moments and effect size.
Results: Using the training dataset the expert opinion crosswalk met all of the criteria except for the direction of population invariance within the race category. The equipercentile methodology satisfied all of the evaluation criteria, and the Rasch model met all of the criteria except for a difference in directionality in the skewness of the distributions as well as not meeting the targeted 80% of scores falling within ½ SD of the reference assessment. These results differed from the validation sample for the population invariance criteria, in which the age categories were in opposite directions and had observed differences between standardized mean difference for age that exceeded the threshold of 0.08 for both the equipercentile and Rasch crosswalks.
Conclusions: All three crosswalk methods produced acceptable criteria for use. Therefore, motor/physical functional outcome can be compared between cohorts having been assessed using different measures. The results indicate that for researchers wanting to compare cohorts that have been assessed using different instruments, any of the crosswalks could be utilized.
218 Longitudinal alterations in cerebral perfusion and verbal memory following a season of adolescent contact sport participation compared to non-contact athletes
Benjamin Brett
ABSTRACT
Background: Preliminary evidence suggests that differences in brain structure and function observed in association with cumulative repetitive head impacts (RHI) may be present in younger active athletes, including changes recorded after a single season of sport participation. Cerebral blood flow (CBF) change is a critical marker of head injury and other pathological processes, but has yet to be thoroughly investigated as a potential consequence of RHI via contact sport participation in active athletes. We examined the difference in pre-to post-season relative (rCBF), arterial transit time (ATT), and neurocognitive changes between adolescent contact and well-match non-contact sport athlete groups.
Methods: Well-matched contact (n = 34) and non-contact (n = 23) middle and high school athletes (mean age 14.70; SD = 1.97) completed a battery of neurocognitive measures and underwent serial neuroimaging at pre- and post-season. The clinical battery included the Immediate Post-Concussion Assessment of Cognition Test (ImPACT) and the Trailmaking Test indices from the Delis-Kaplan Executive Function System. Brain perfusion was evaluated using an advanced 3D pseudo-continuous ASL (pCASL) sequence with Hadamard encoded multiple post-labeling delays (PLDs). Linear mixed-effects models were fit to test the effects of time (pre- to post-season difference), contact group (contact vs. non-contact), and group-by-time interactions in rCBF, ATT, and neurocognitive performance. Covariates within models included history of prior concussion, age, and BMI specifically for rCBF/ATT. Multiple comparisons were controlled for using a cluster size correction technique.
Results: A significant group-by-time interaction effect was observed for ImPACT Verbal Memory performance, B = −13.87, SE = 5.16, p = 0.01. Specifically, while non-contact sport athletes improved over time from pre- to post-season (pre-season mean score = 82.22 [SE = 2.99]; post-season mean score = 90.10 [SE = 3.70]), contact sport athletes declined from pre-to post-season (pre-season mean score = 84.34 [SE = 2.56]; post-season mean score = 78.35 [SE = 2.89]). A significant group-by-time interaction effect was also observed for rCBF in a cluster centered at MNI coordinates (34,-14,54) that consisted of pre- and post-central gyri, superior parietal lobule, and inferior and middle frontal gyri regions (cluster size = 6497 voxels, maximum z-score = 4.53). Post-hoc analyses revealed that the interaction effect was driven by significant rCBF increases in contact athletes and rCBF decreases among non-contact athletes in generally overlapping regions. Significant time and interaction effects were not observed for ATT at a cluster-corrected p < 0.05.
Conclusions: Alterations in verbal memory and cerebral blood flow, but not purported neurovasculature structural changes (measured by ATT), were observed following a single season of contact sport participation. Cerebral perfusion changes may represent one pathway by which exposure to RHI represents a potential risk factor for adverse long-term outcomes in contact athletes. Future studies are needed to examine the course of these changes following exposure to cumulative seasons of contact sport participation and recovery of observed effects with avoidance of further exposure and between years of contact sport participation.
220 Community integration 10 years after moderate-to-severe traumatic brain injury
Prof. Juan Lua,c, Mari Rasmussenb,e, Marit Forslundb, Emilie Howeb, Silje Fureb, Marianne Løvstadf,g, Cecilie Røeb,c,d, Nada Adelicb,c
aDivision of Epidemiology, Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, USA, bDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, cInstitute of Health and Society, Research Center for Habilitation and Rehabilitation Models & Services (CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway, dFaculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway, eInstitute of Rehabilitation Science and Health Technology, Faculty of Health Sciences, OsloMet – Oslo Metropolitan University, Oslo, Norway, fDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, gResearch Department, Sunnaas Rehabilitation Hospital, Bjørnemyr, Norway
ABSTRACT
Background and Aims: Better understanding of long-term functional recovery and community integration for patients with traumatic brain injury (TBI) facilitates effective rehabilitation. This study describes community integration after moderate-to-severe traumatic brain injury and assesses the impact of baseline demographics, injury characteristics, and one-year post-injury functional level on community integration 10 years after injury.
Methods: Patients with moderate-to-severe traumatic brain injury (ICD-10 S06.0–S06.9), aged 16–55 years, were eligible for the study. All patients were admitted to a Trauma Referral Hospital within 24 hours of injury. Demographics and injury characteristics were documented on admission, and functional status and level of community integration were recorded at 1- and 10-year follow-ups. Injury severity was evaluated with the Glasgow Coma Scale (GCS), head CT scan (modified Marshall Classification), and Injury Severity Score (ISS). Functional status was assessed with the Functional Independence Measure motor (FIM-M) and cognitive (FIM-C) subscales, Mental Health (MH) and Bodily Pain (BP) dimensions of the Medical Outcomes 36-item Short Form Health Survey (SF-36), and the Community Integration Questionnaire (CIQ). Multivariate linear regression was applied to assess 10-year CIQ scores controlling for baseline characteristics and one-year functional level.
Results: Of 97 participants, 75 patients were available at 10 years of follow-up and analysis. Mean age at injury was 30 (±11) years, 76% were male and 59% were injured in traffic accidents. At admission, the mean GCS score and ISS were 7 (±3) and 30 (±14), respectively. At 1-year, the mean FIM-M and FIM-C scores were 86 (range 13–91) and 32 (range 12–35), respectively; mean MH was 70 (range 8–100) and mean BP was 66 (range 10–100). The total CIQ score changed positively from 1- to 10-year follow-up, from 18.7 (±5.5) to 19.8 (±4.8) (p < 0.001). Older age (beta = −0.276, p = 0.01) was negatively associated while higher levels of cognitive functioning (beta = 0.522, p = 0.01) and less bodily pain (beta = 0.250, p = 0.05) at 1 year were positively associated with higher levels of community integration 10-years post-injury.
Conclusions: This study demonstrated improved community integration from 1 to 10 years following moderate-to-severe TBI. The study results also suggested that age, cognitive function, and bodily pain are important predictors of long-term community integration for patients with TBI. In post-acute TBI rehabilitation, it is essential to focus on factors related to both long-term risks and protective factors, and pain management to improve outcomes in the chronic phase.
221 The added value of clinical neuropsychology to neuro-navigation: a pilot project in South West London, UK
Cliodhna Carrolla, Bethan Armitagea, Jennifer Barrassa, Rachel Jefferya, Jade Kinga, Sam Pursera, Shai Betteridgeb
aSouth West London Integrated Care Board, London, United Kingdom, bSt George’s Hospital, London, United Kingdom
ABSTRACT
The United Kingdom’s (UK) National Health Service (NHS) has excessive waiting times for admission to specialist neurorehabilitation services, which provide for patients with complex needs (i.e. Level 1 units). Neuropsychological factors including cognitive deficits, mood and behavioral disturbances impact on patients’ engagement and rehabilitation potential, causing delays in discharge from acute hospitals. There is little research on the impact of the setting where neuropsychological rehabilitation is provided on patient outcomes. The majority of patients wish to leave hospital and return home as early as possible. The NHS South West London (SWL) Neuro Navigation Plus (SWL NN+) pilot project was commissioned to facilitate more efficient discharge and pathway management of neurological patients. Neuropsychology alongside neuro-navigation in-reached into acute hospitals to support patients where neuropsychological needs impact on their hospital discharge; or out-reached into community settings where patients were at risk of re-admission to hospital or referral to level 1 units. In the first four months of the project (June–September 2022), 23 referrals (14 males and 9 females, age range 18–84 years, x = 49.9 years) were accepted out of 29 referred to the neuropsychology team. Patient diagnoses were stroke (n = 11), traumatic brain injury (n = 5), encephalitis (n = 2), alcohol-related hepatic encephalopathy (n = 2), spinal cord injury (n = 2), hypoxic brain injury (n = 1) and legionnaire’s disease (n = 1). A number of patients presented with comorbidities which negatively impacted on their rehabilitation pathway, including drug and alcohol misuse (n = 5), premorbid mental health difficulties (n = 4), suicide attempt as cause of injury (n = 2), forensic history (n = 2), homelessness (n = 2), psychotic experiences post-injury (n = 2) and domestic violence (n = 1). Reasons for referral included assessment (e.g., differential diagnosis, risk and capacity); and intervention for cognition, psychiatric disorders, behavioral management, family and staff support. On entry to the service, 16 patients completed self-rated mood screening tools. Of these, 12 patients had symptoms of depression (mild = 9, moderate = 1, severe = 2) and eight anxiety (mild = 2, moderate = 4, severe = 2). Twenty patients experienced cognitive difficulties. Written documentation formulating the patients’ presentation, needs and goals was provided for all patients, to guide neuro-navigators and staff teams’ holistic working and aid onward referrals. Results to date demonstrated a 5.8% reduction in specialist inpatient rehabilitation waiting list for SWL, improved patient care, and more efficient patient pathway management as a result of integrating neuropsychology into the neuro-navigation team. Eight patients have been supported to avoid a specialist rehabilitation unit admission, three were accepted to inpatient rehabilitation quicker, one was safely discharged to a residential placement, and one patient’s family felt confident to support their discharge home. Staff feedback has noted the benefit of neuropsychology with neuro-navigation to address patients’ unmet needs.
222 Gender differences in knowledge of intimate partner violence and intimate partner violence-caused brain injury in Western Canadian paramedics
Rory A. Marshalla,b, Isaac J. Koolb,c, Alanna Shweda,d, Tori N. Strangesa, Heather L. Gainfortha,d, Simon Sawyere,f, Paul van Donkelaara
aUniversity Of British Columbia Okanagan, Kelowna, Canada, bBritish Columbia Emergency Health Services, Vancouver, Canada, cCamosun College, Victoria, Canada, dInternational Collaboration of Repair Discoveries, Vancouver, Canada, eGriffith University, Southport, Australia, fAustralian Paramedical College, Burleigh Waters, Australia
ABSTRACT
Background: Intimate partner violence (IPV) is excluded from the educational curriculum and vocational aptitudes mandated for Canadian paramedics (National Occupational Competency Profile). Paramedics frequently encounter patients experiencing ongoing IPV, either knowingly or unknowingly. Likely, the management of these patients relies heavily on each paramedic’s societal familiarity with IPV. Further, up to 90% of survivors of physical IPV report signs and symptoms consistent with brain injury. Thus, vocational deficits for Canadian paramedics may exist surrounding both IPV and IPV-caused brain injury (IPV-BI). Whether paramedic knowledge of IPV and IPV-BI is impacted by gender (socially constructed roles, identities, and behaviors) differences remains unknown.
Objective: To examine if the gender of Western Canadian paramedics impacts knowledge of IPV and IPV-BI.
Methods: British Columbia, Alberta, and Saskatchewan paramedics completed an anonymous online survey. Five psychometrically validated IPV questions (READI Scale, 7-point Likert) and two supplemental IPV-BI questions (7-point Likert) were pooled to examine IPV and IPV-BI knowledge, respectively. Between gender knowledge of IPV and knowledge of IPV-BI, and within gender knowledge of IPV versus IPV-BI were explored by t-tests and Cohen’s d effect size (d). Comparative data is presented as mean±standard deviation. Significance was considered at P < 0.0125 (Bonferroni correction). RESULTS: N = 165 paramedics completed the survey (Women 49% [n = 81], Men 50% [n = 83], Prefer Not to Answer 1% [n = 1]). Respondents were predominantly cisgender (99% [n = 163]). Women scored higher than men on knowledge of IPV (women 6.1 ± 0.7 versus men 5.8 ± 0.7, P = 0.004, d = 0.5), but not on knowledge of IPV-BI (women 4.6 ± 0.9 versus men 4.3 ± 0.9, P = 0.051, d = 0.3). Both women and men scored higher on knowledge of IPV compared to knowledge of IPV-BI (women 6.1 ± 0.7 versus 4.6 ± 0.9, P < 0.001, d = 1.9; men 5.8 ± 0.7 versus 4.3 ± 0.9, P < 0.001, d = 2.0).
Conclusion: Paramedics who identify as women demonstrated greater knowledge of IPV versus men (medium, positive effect). No difference in knowledge of IPV-BI was observed between genders, but both genders demonstrated more knowledge of IPV than IPV-BI (large, positive effects). Although paramedic knowledge of IPV was better than anticipated, the interrelation to IPV-BI is not yet widely established in Western Canadian paramedicine. An ongoing effort is needed to firmly establish correct and applicable knowledge of IPV and IPV-BI for all providers in prehospital care.
225 Novel guidelines to support clinical decision-making for post stroke fatigue management
Anthony Walsha, Merrill Turpinb, Suvendra Anandalingamb, Hannah Gullob
aCommunity Based Rehabilitation Team, Metro North Hospital and Health Service, Brisbane, Australia, bSchool of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
ABSTRACT
Background: Limited clinical decision-making tools and guidelines exist for clinicians to use during therapy with patients who experience post stroke fatigue. In evidence-based practice, clinical decisions are formulated using four sources to inform therapy plans: the patient’s experience, the clinician’s expertise, the local organizational context, and the research evidence. Novel clinical tools, guidelines and templates were created, within a hospital and health service, to support decision-making for post stroke mental fatigue management in a community rehabilitation setting.
Objectives: In this study we aimed to: i) determine how useful clinicians’ perceived resources to be after implementation; ii) understand their clinical decision-making process; and iii) explore patients’ thoughts on their experience after receiving tailored treatment.
Methods: We used a qualitative survey design. Four occupational therapists and 16 adult stroke patients, referred to community-based rehabilitation across four sites, were surveyed following a 10-week intervention period. The fatigue management resources included a purpose made Clinical Guideline Flowchart, Prioritization Matrix Tool and Electronic Routine Template. Data was collected using Qualtrics, a secure online survey platform and analyzed using content analysis.
Results: Clinicians and patients indicated the usefulness of the resources during therapy. Clinicians’ and patients’ views on the useability of the resources, accessibility of the resources, and barriers and facilitators to using and accessing the resources were key elements identified as important.
Conclusions: Findings suggest that there was a positive influence on clinicians’ decision-making, assessment choice, application of clinical tools in interventions and strategy implementation in practice. The novel guidelines and tools were perceived useful by clinicians and patients alike, and may continue to be utilized to support post stroke fatigue management.
226 Physical activity interventions for people with moderate-to-severe traumatic brain injury: a rapid systematic review and meta-analysis
Gavin Williamsa,b, Liam Johnsona,c, Kavya Pillid, Sakina Chagpare, Aylish Auchettlb, Jack Beardb, Renee Gillb, Gabrielle Vassallof, Nick Rushworthg, Sean Tweedyh, Grahame Simpsond,i, Adam Scheinberga,j, Kelly Clanchyk,l, Anne Tiedemanne,m, Catherine Sherringtone,m, Leanne Hassette,n
aSchool of Health Sciences, Faculty of Medicine, Dentistry and Health Sciences, The University Of Melbourne, Melbourne, Australia, bPhysiotherapy Department, Epworth HealthCare, Melbourne, Australia, cSchool of Behavioral and Health Sciences, Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia, dLiverpool Brain Injury Rehabilitation Unit, South Western Sydney Local Health District, Sydney, Australia, eInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia, fConsumer Representative, Sydney, Australia, gBrain Injury Australia, Sydney, Australia, hSchool of Human Movement and Nutrition Sciences, Faculty of Health and Behavioral Sciences, University of Queensland, Brisbane, Australia, iJohn Walsh Center for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District and The University of Sydney, Sydney, Australia, jMurdoch Children’s Research Institute, Melbourne, Australia, kSchool of Health Sciences and Social Work, Griffith Health, Griffith University, Gold Coast, Australia, lMenzies Health Institute of Queensland, Griffith University, Gold Coast, Australia, mSydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia, nSydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
ABSTRACT
Background: People with moderate-to-severe traumatic brain injury (TBI) are highly inactive, and there is a lack of consensus on what physical activity is appropriate and optimal. In 2020, the World Health Organization (WHO) released the first global physical activity and sedentary behavior guidelines for people living with disability, however the evidence informing these guidelines was not TBI-specific and did not include physical activity interventions during rehabilitation. PURPOSE: To identify direct evidence of the effects of physical activity on health outcomes in people with moderate-to-severe TBI. This review aims to inform the applicability of the WHO guidelines to people with moderate-to-severe TBI and support the adaptation of these guidelines into clinical practice guidelines.
Methods: We conducted a rapid systematic review with meta-analysis following Cochrane recommended methods. Four databases (CENTRAL, SPORTDiscus, PEDro and Ovid MEDLINE) were searched from inception to October 8, 2021. Studies were included if they were randomized controlled trials, included people of any age with moderate-to-severe TBI, investigated physical activity interventions compared to either usual care, a physical activity intervention with different parameters, a nonphysical activity intervention, or waitlist/no intervention. The primary outcomes of interest were physical function, including composite mobility, balance, walking, global function, cardiorespiratory fitness, muscle strength, body composition and fatigue, cognition, quality of life. Secondary outcomes included mortality, comorbid conditions, mood, participation, and physical activity. We calculated mean difference (MD) or standardized mean difference and 95% confidence intervals (95%CI) using a random-effects model to pool estimates. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to assess the certainty of the evidence.
Results: Twenty-three studies were included incorporating 812 participants (36% females, average age ranging from 22 to 52 years, time post-TBI in studies ranged from 56 days (median) to 16.6 years (mean)). A range of physical activity interventions were evaluated, including aerobic exercise (n = 2 studies), gait/balance/function (n = 12), multicomponent training (n = 5), sport and recreation (n = 2), and overall physical activity promotion (n = 2). The interventions were tested in rehabilitation (n = 12), community (n = 8) and home (n = 3) settings. We pooled data from the end of the intervention for eight outcomes. Participation in a virtual reality physical activity intervention improved mobility more than standard balance training (2 studies, 80 participants, MD = 2.78, 95%CI 1.40 to 4.16; low certainty evidence). There was uncertainty of effect for the remaining outcomes, limited by small sample sizes, diverse comparators and a wide range of outcome measures.
Conclusions: This review consolidates the current evidence base for the prescription of physical activity for people with moderate-to-severe TBI. There remains a pressing need for further rigorous research to inform the development of clinical practice guidelines to support clinical decision-making when prescribing and promoting physical activity to people with moderate-to-severe TBI.
227 Loneliness in acquired brain injury; a qualitative exploration of lived experience
Robert Raucha, Orla Duffyb, Katy Pedlowb, Julie- Ann Jordanc, Jacqueline Poguea, Laura Dunlopa, Rachel Agnewa, Ian Taylora
aBrain Injury Service, Northern Health and Social Care Trust, United Kingdom, bUlster University, Derry/Londonderry, United Kingdom, cIMPACT research center, Northern Health and Social Care Trust, United Kingdom
ABSTRACT
Background: Loneliness is growing into one of the biggest health concerns in the UK and is recognized as a health priority in Northern Ireland (Northern Area Loneliness Framework, NHSCT, 2021). Following acquired brain injury (ABI), there is a sudden and catastrophic loss in functioning impacting on many areas of life. Communication is affected and social interactions change impacting relationships (Salas et al 2020). Studies have reported a change in self-identity and impaired psychological adjustment impacting on participation in society (Carroll & Coetzer 2011). A recent study on older adults in Northern Ireland (NI) (Cruise& Kee,2017) has highlighted how NI can be thought of uniquely in the area of loneliness due to the unique cultural values of religiosity and large extended families with strong kinship ties. This study set out to explore the meaning of loneliness for adults with lived experience of ABI and the experience and factors influencing loneliness in this population.
Methods: This qualitative study included three focus groups and four individual interviews which were conducted using a semi structured interview guide and recorded online. Participants were recruited from the Community Brain Injury team caseload. Twenty-three adults (6 female, 17 male), ranging from 2–24 years post ABI participated. Data was analyzed thematically using Analytic induction to guide the development of themes.
Results: The term loneliness had a different meaning to all participants, yet all had experienced it at some point of their journey post ABI. Five main themes were identified; how loneliness feels, consequences of brain injury, identity, coping and the impact of covid. Participants provided suggestions to support people with ABI in the future, based on their own experience. Sub themes were derived providing an in-depth exploration.
Conclusions: Supporting loneliness post ABI is challenging and multifactorial. Early identification and support by clinical teams is crucial. The findings suggest some mechanisms to provide such support, directly from those with lived experience.
228 The process of assessing and managing fatigue in children and adolescents with moderate to severe acquired brain injury from the perspectives of rehabilitation clinicians
Olivia Mazzonea,b, Rowena Conroyb, Taylor Jenkina,b, Adam Scheinberga,c,d, Sarah Knighta,b,c,d
aMurdoch Children’s Research Institute, Parkville, Australia, bMelbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia, cDepartment of Pediatrics, The University of Melbourne, Melbourne, Australia, dVictorian Pediatric Rehabilitation Service, Royal Children’s Hospital Melbourne, Parkville, Australia
ABSTRACT
Background: Fatigue is common following pediatric acquired brain injury (ABI) and can negatively impact children’s and adolescents’ quality of life by limiting their participation in activities across home, school, and social contexts. Despite the frequency and impact of fatigue on children and adolescents with ABI, there are limited evidence-based, best practice guidelines to assist clinicians in assessing and managing fatigue following pediatric ABI and our understanding of how clinicians currently assess and manage fatigue in rehabilitation is inadequate.
Objective: This study aimed to explore how rehabilitation clinicians recognize, assess, and manage fatigue following moderate to severe pediatric ABI.
Methods: Purposive sampling was used to recruit clinicians who work with children and adolescents with ABI at the Victorian Pediatric Rehabilitation Service. Using a qualitative research design, semi-structured interviews were conducted with 11 clinicians (10 female, 1 male) with varying years of clinical experience (Mdn = 11, range: 4–25), working across metropolitan and regional sites, and across disciplines (medical, neuropsychology, physiotherapy, occupational therapy, social work, and speech pathology). Interview transcripts were analyzed using constructivist grounded theory methods.
Results: Two main themes and sub-themes were developed: (1) Reaching a Shared Understanding: Identifying and understanding fatigue; and Unpacking fatigue with the family; and (2) Using the shared understanding: Working collaboratively to manage fatigue; Planning for and managing transitions; and Anticipating and problem-solving speedbumps. Participants reflected on the importance of developing an individualized understanding of fatigue within each child’s/adolescent’s unique personal context, relying on the communication and shared understanding among the child/adolescent with ABI, family, and members of the rehabilitation team. The findings also highlight the collaborative nature of fatigue management whereby the clinicians, child/adolescent, family, and school plans and problem-solves fatigue management together over time.
Conclusions: These findings provide insights into clinicians’ experiences recognizing, assessing, and managing fatigue following moderate to severe pediatric ABI. Further investigation is required to explore fatigue recognition, assessment, and management from the perspective of children/adolescents with ABIs and families. This study highlights the importance of a collaborative approach to reaching and using a shared understanding of fatigue to support the child/adolescent with ABI during their rehabilitation.
229 An outlier analysis for acute blood biomarkers of moderate and severe traumatic brain injury
Otto Korhonena,b,c, Malla Mononena,b,c, Mehrbod Mohammadianb,c, Jussi Postia,b,c, Henna-Riikka Maanpääa, Virginia Newcombed, David Menond, Peter Hutchinsone, Henrik Zetterbergf, Kaj Blennowf, Jean-Charles Sanchezg, Leire Azurmendig, Linnea Lagerstedtg, Ari Katilah, Riikka Takalah, Jussi Tallusi, Prof. Olli Tenovuob,c
aNeurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland, bTurku Brain Injury Center, Turku University Hospital, Turku, Finland, cDepartment of Neurology, University of Turku, Turku, Finland, dDivision of Anesthesia, Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom, eDivision of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom, fof Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, Shalgrenska Academy at the University of Gothenburg, Mölndal, Sweden, gDepartment of Specialties of Internal Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland, hPerioperative Services, Intensive Care Medicine and Pain Management, Department of Anesthesiology and Intensive Care, Turku University Hospital, University of Turku, Turku, Finland, iDepartment of Radiology, Turku University Hospital, University of Turku, Turku, Finland
Question: Blood biomarkers have been studied to improve the clinical assessment and prognostication of patients with moderate – severe traumatic brain injury (mo/sTBI). To assess their clinical usability, one needs to know potential factors that might cause abnormal values and affect clinical decision-making.
ABSTRACT
Methods: In a prospective study we recruited patients with mo/sTBI (n = 85) and measured the blood levels of eight protein biomarkers (GFAP, S100B, NFL, H-FABP, IL-10, t-tau, amyloid B40, and amyloid B42) within 24 hrs of admission. Similar analyses were conducted for controls (n = 40) with an acute orthopedic injury in absence of head trauma. The patients with TBI were divided into subgroups of normal vs. abnormal (n = 10/75) head CT and favorable (Glasgow Outcome Scale extended = GOSe 5–8) vs. unfavorable (GOSe < 5) (n = 42/38, 5 missing) outcome. Biomarker levels outside ± 1.5 IQR were considered as outliers. The medical records of each outlier patient were gone through in a team meeting to determine possible reasons for abnormal values.
Results: In the CT subgroups, 21 patients (25%), and in the outcome subgroups, 23 patients (27%) showed abnormal values in at least one biomarker. Among the controls 12 (30%) showed abnormal values. Several patients had abnormal values in more than one biomarker (up to 4) in all subgroups. All abnormal values were higher than +1.5 IQR. A logical explanation was found for almost all cases, with the exception of amyloids and tau. Explanations for high values included extremely severe injury, esp. for GFAP and S100B all outliers in the CT subgroups died because of the injury. In case of H-FABP and IL-10 the explanation was extracranial injuries (thoracic injuries for H-FABP and multi-trauma for IL-10), in some cases these also associated with abnormally high S100B. Sampling related factors and demographic factors such as earlier head injuries or neurological conditions and old age explained some of the abnormally high values (esp. for NFL). Similar explanations also emerged in controls, where the abnormal values were caused especially by preexisting neurological diseases.
Conclusion: In order to utilize blood-based biomarkers in clinical assessment of mo/sTBI, preexisting health issues, extremely severe injuries, multi-trauma, and temporal factors must be taken into consideration. Very high levels seem to be often associated with poor prognosis and mortality (GFAP and S100B). This information is important for decision-making in clinical settings.
230 Executive functions after severe traumatic brain injury in adults: difficulties reported in the dysexecutive questionnaire and comparison with the normal population
Hugo Câmara-Costaa,b, Mathilde Chevignarda,b,c, Georges Dellatolasb, Philippe Allaind,e, Claire Jourdanf, Alexis Ruetg, Eléonore Bayena,h, Claire Vallat-Azouvii,j, Philippe Azouvii,j
aSorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale, LIB, F-75006, Paris, France, bSorbonne Université, GRC 24, Handicap Moteur Cognitif et Réadaptation – HaMCre, Paris, France, cService de Rééducation des Pathologies Neurologiques Acquises de l’Enfant, Saint-Maurice, France, dLaboratoire de Psychologie des Pays de la Loire (LPPL EA 4638), Université d’Angers, Nantes, France, eUnité de Neuropsychologie, Département de Neurologie, CHU Angers, Nantes, France, fCentre Hospitalier Universitaire de Montpellier, Service de Médecine Physique et de Réadaptation, Montpellier, France, gCentre Hospitalier Universitaire de Caen, Service de Médecine Physique et de Réadaptation, Caen, France, hAssistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Service de Médecine Physique et Réadaptation, Paris, France, iAntenne UEROS – UGECAM IDF, Hôpital Raymond Poincaré, Garches, France, jUniversité Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, Villejuif, France, kAssistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, Service de Médecine Physique et de Réadaptation, Garches, France
ABSTRACT
Introduction: The Dysexecutive Questionnaire (DEX) is an ecologically valid measure of executive function disorders after acquired brain injury. It is sometimes used as a measure of anosognosia, especially in the case of severe Traumatic Brain Injury (TBI). After severe TBI, when the DEX is completed by patients, high scores are expected in the presence of recognized executive disorders and low scores if there is denial or lack of awareness of these disorders. Despite its widespread use in the assessment of executive functions following severe TBI, its lack of standardized norms limits the contextualization of an individual’s performance in comparison to a normative population. This study aimed at comparing the distribution of self- and proxy-reported DEX scores 8-years after severe TBI in the participants enrolled in the PariS-TBI cohort to that of a control group.
Method: The PariS-TBI study included 504 adults (ages > 15 years) with severe TBI (GCS score ≤ 8 before hospital admission), who were assessed longitudinally 8-years post-injury. At the 8-year follow-up, 268 patients were deceased (213 during the acute stage), 128 patients were lost to follow-up and 22 refused to participate, resulting in a sample of 86 participants, which was retained for the present analyses (ages 24 to 82 years). Executive functions were assessed with the DEX questionnaire (self-, n = 76 and proxy-reports, n = 46; Minimum score = 0, Maximum = 80). We compared the distribution of the DEX total score observed in participants who underwent severe TBI with the distribution of a control group (n = 86) matched by age and gender using Fischer’s exact tests.
Results: In the control group, self- and proxy-reported scores tended to scatter according to a normal distribution. The percentage of DEX scores that were equal to 0 or extremely low (0 to 5, indicating absence or few complaints regarding executive functions) was significantly higher in the group of participants with severe TBI, both in self- (21% versus 6%, p = 0.005) and proxy-reports (19% versus 1%, p = 0.0004). The same pattern was observed for extremely high scores (indicating a significant presence of difficulties in executive functioning): self- (15% versus 0%, p < 0.0001), proxy-reports (18% versus 1%, p = 0.04).
Discussion: These observations underline the importance of examining the distribution of the DEX questionnaire scores and encourage practitioners to interpret further these scores beyond a comparison of the means. These results underline the factors that may be associated with the discrepancy observed between self- and proxy-reports of executive functions, and point to the possibility of defining groups of patients according to the knowledge (or acceptance) of their difficulties, both in self- and proxy-reports, which should be considered in the management and rehabilitation following severe TBI.
231 Residual implicit versus explicit language abilities in patients with disorders of consciousness
Charlène Aubineta, Camille Chatellea, Olivia Gosseriesa, Manon Carrièrea, Steven Laureysa, Steve Majerusa
aUniversité De Liège, Liège, Belgium
ABSTRACT
The assessment of patients with disorders of consciousness (DoC) is limited and leads to significant clinical misdiagnosis. The presence of language deficits might particularly lead to an underestimation of consciousness levels in unresponsive wakefulness syndrome (UWS) or minimally conscious state (MCS; -/+) diagnoses. Our systematic review analyzed the literature on residual language processing in DoC patients, as assessed by neuroimaging, electrophysiological and behavioral techniques. Our main goal was to (1) identify the level and quality of language residual abilities as a function of DoC diagnosis; and (2) examine how implicit (i.e., cortical responses to specific words/sentences) and explicit (e.g., command-following) language abilities reappear after severe brain injury. Eighty-five articles including a total of 2278 patients were assessed for quality, and median percentages of patients showing implicit versus explicit receptive language skills were examined. Implicit language abilities were shown in 33% of UWS, 50% of MCS-, 78% of MCS+ and 83% of patients emerging from the MCS, and encompassed domains such as language recognition, detection of intelligibility, as well as lexical and semantic processing of words and sentences. Evidence of explicit language processing was further reported in 20% of UWS, 33% of MCS-, 50% of MCS+ and 100% of patients emerging from the MCS. Cortical responses to verbal stimuli increased along with consciousness levels and the progressive recovery of consciousness after a coma was paralleled by the reappearance of both implicit and explicit language processing. Our results raise various theoretical and clinical issues and should be taken into account when diagnosing post-comatose DoC. This review finally highlights the importance of language assessment in DoC patients.
232 Age-related effects on overall disability, motor function and psychosocial outcome 7 to 8 years after severe traumatic brain injury: results from the traumatisme grave de l’Enfant and the PariS-TBI studies
Hugo Câmara-Costaa,b, Leila Francillettea, Hanna Tourec, Anne Laurent-Vannierc, Philippe Meyerd, Claire Jourdane, Eléonore Bayena,f, Alexis Ruetf, Claire Vallat-Azouvih,i, Georges Dellatolasb, Philippe Azouvii,j, Mathilde Chevignarda,b,c
aSorbonne Université, CNRS, INSERM, Laboratoire d’Imagerie Biomédicale (LIB), F-75006, Paris, France, bSorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCre), Paris, France, cRehabilitation Department for Children with Acquired Brain Injury, and Outreach team for Children and Adolescents with Acquired Brain Injury, Paris, France, dAssistance Publique des Hôpitaux de Paris (APHP) Center – Université de Paris, Paris, France, ePhysical Medicine and Rehabilitation Department, Lapeyronie Hospital, CHRU, Montpellier, France, fAssistance Publique-Hôpitaux de Paris (APHP), Groupe Hospitalier Pitié-Salpêtrière, Service De Médecine Physique Et Réadaptation, Paris, France, gPhysical Medicine and Rehabilitation Department, CHU Caen, INSERM U1077, Caen, France, hAntenne UEROS – UGECAM IDF, Hôpital Raymond Poincaré, Garches, France, iUniversité Paris-Saclay, UVSQ, Inserm, CESP, Team DevPsy, Villejuif, France, jAssistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, Service De Médecine Physique Et De Réadaptation, Garches, France
ABSTRACT
Introduction: Age at injury is amongst one of the most important factors influencing long-term overall outcome following severe childhood traumatic brain injury (TBI) both during childhood (younger age usually associated with worse outcomes) and in adulthood (worse outcomes in older patients). However, methodological issues have limited the amount of studies examining long-term outcomes after severe TBI over a wide age span. The purpose of this study was to investigate the effect of age at injury on overall disability, persistent motor impairments, and psychosocial outcome by comparing data from two prospective longitudinal cohorts of children/adolescents and adults assessed 7 to 8 years after severe TBI.
Methods: We combined data from the Traumatisme Grave de l’Enfant (TGE) cohort, which assessed 39 children/adolescents 7-years following severe TBI [mean age at injury (SD) = 7.5 years (4.6), range 0.3–14.7], and the PariS-TBI cohort, comprising 86 adults assessed 8-years post-severe TBI [M (SD) = 33.7 years (13.8), range 14.6–74.3]. Follow-up assessments included comparable measures of overall disability (Glasgow Outcome Scale Extended [GOSE]), neurological recovery, and self- and/or proxy-reported questionnaires assessing school/work situation, anxiety/depression symptoms, quality of life and perceived burden by the caregiver.
Results: Despite significantly shorter length of coma in children than in adults, the level of overall disability (GOS-E) was similar across age groups. Younger age at injury was significantly associated with persistent motor deficits. Adults reported significantly greater fatigue levels than children. In children/adolescents, the Injury Severity Score predicted uniquely the post-injury GOS-E score, while for adults the most significant predictors were the Glasgow Coma Scale score, coma duration and the number of completed years of education. For both children/adolescents and adults, overall disability 7 to 8 years post-injury correlated with a range of concurrent difficulties including school/work adaptations, presence of motor deficits and anxiety/depression symptoms, lower health-related quality of life and higher levels of perceived burden reported by the caregivers.
Discussion: Our results indicated that overall disability 7/8 years post-injury was not significantly associated to age at injury. Despite shorter lengths of coma, children exhibited high levels of overall disability that were similar to the adult cohort. Children under 6 years seem to represent a particularly vulnerable risk for exhibiting severe disability 7-years post-injury, compared to school-aged children, adolescents and adults. The higher prevalence of persistent motor deficits in adults than in children is coherent with clinician’s experience. In adults, pre-injury level of education was strongly related to good recovery levels 7–8 years post-injury, while parental education level of children (used as a proxy for socio-economic status) was not. These results provide unique insights on the effect of age on long-term outcomes following severe TBI, and underline the potential of using comparable measures for assessing overall and specific outcomes among pediatric and adult population.
233 The eye-tracked brief evaluation of receptive aphasia: a new tool to assess residual language comprehension abilities in post-comatose patients
Charlène Aubineta, Lucie Mazuéb, Mélanie Mulerob, Didier Schwabc
aUniversité de Liège, Liège, Belgium, bUniversité Toulouse III – Paul Sabatier, Toulouse, France, cUniversité Grenoble Alpes, Grenoble, France
ABSTRACT
Assessing verbal comprehension in post-comatose patients with severe brain injury seems essential to improve their diagnosis and care. Recently, a specific tool for the assessment of verbal comprehension in these patients has been developed: the Brief Evaluation of Receptive Aphasia (BERA). This assessment is based on visual fixation responses, yet judging these fixations by simple observation is often complex and open to interpretation. The use of an eye-tracking setting to accurately and objectively examine eye movements seems the most interesting to improve the sensitivity and reliability of the BERA tool. Based on the Delphi method, we here investigated the relevance of eye-tracker in the assessment of verbal comprehension in post-comatose patients, using a computerized version of the BERA assessment: the eye-tracked BERA (ET-BERA). The content and feasibility of the ET-BERA were evaluated by a panel of 18 experts, including 13 speech therapists, 2 occupational therapists, 2 neuropsychologists and one orthoptist. All experts highlighted the need for language-specific assessment tools as well as the relevance of eye-tracking use in post-comatose patients, and the content criteria were validated. As regards the feasibility, several modifications were suggested to reduce both assessment duration and visual distractors. The ET-BERA is a promising tool to examine the language profile of post-comatose patients, and future studies are needed to test and validate the proposed modifications in this challenging population.
234 The changing process of hope in family members after ABI – a longitudinal qualitative analysis
Valentina Curroa, Alyson Normana, Mark Hollowayb, Charlotte Whiffinc
aUniversity Of Plymouth, Plymouth, United Kingdom, bHead First – Assessment, Rehabilitation & Case Management, Hawkhurst, United Kingdom, cUniversity of Derby, Derby, United Kingdom
ABSTRACT
Background: Acquired brain injury (ABI) is a dramatic life-changing event not only for the survivors, but also for their family members. For years, the stories of families affected by brain injury have been largely ignored or simply examined through measures of stress, depression, anxiety, and quality of life. Recently, there has been an increased interest in how family members make sense of and/or understand their lives post-injury. This study aims to offer new insights into the unique narratives of family members navigating the different stages of rehabilitation with a particular focus on the concept of ‘hope’ and its role in empowering family members, facilitating coping and adjustment, and promoting wellbeing after brain injury.
Methods: Family members, involved with the recovery of ABI survivors, were asked to take part in three one-to-one semi-structured interviews. The second and third interviews were conducted three and six months after the first interview. Participants were given the option to be interviewed in person at their preferred location or remotely via Zoom or Microsoft Teams. A semi-structured interview guide was used to gain a deeper understanding of their long-term experiences accessing rehabilitation services and supporting the person with ABI.
Results: Hope appears to be a dynamic construct that changes throughout the rehabilitation journey, assuming different characteristics. In the Intensive Care Unit, family members navigate a continuum between despair and the hope that their loved one will survive. They experience a roller coaster of emotions including anxiety, stress, uncertainty, and fear as they find themselves in ‘unknown territory’ (hope in abeyance). At this stage, feelings of hope are related to the experiences of the present moment as family members look for small positive signs that keep the hope for ultimate survival alive. In the High Dependency Unit, hope changes; family members experience a combination of feelings of uncertainty and hopes for the future (tension between hope for recovery and return to normal life versus the unpredictability of outcomes). Following discharge from the hospital and integration into the community, family members are hopeful that the person with ABI will settle, will feel understood, and will be able to live a meaningful life. They also wish to find the right support to relieve the burden of becoming a full-time carer, and to take on their responsibility of care in the future (legacy planning).
Clinical Implications: Family members need to hold on to hope and feel hopeful. It is important that healthcare professionals and service providers are aware of this. For example, the communication of key information (health prognoses, etc.) needs to be realistic but it also needs to protect and (where applicable) foster hope in family members.
235 History repeating? Failing to learn the lessons from safeguarding adults reviews into the deaths of people with an acquired brain injury: findings from both a mixed methods study of brain injury case managers experiences of safeguarding clients with brain injury and a thematic analysis of recent SAR’s; what can we learn, what have failed to learn?
Alyson Normana, Mark Hollowayb
aUniversity Of Plymouth, Plymouth, United Kingdom, bHead First Case Management, Hawkhurst, United Kingdom
ABSTRACT
Acquired brain is often associated with invisible executive impairments that can leave individuals at significant risk of harm and abuse in the community. The purpose of this research programme was to 1) review UK safeguarding adults reviews (SARs) pertaining to individuals with Acquired Brain Injury (ABI) since 2014 to identify key themes across cases and 2) to understand the experience of Brain Injury Case Managers (BICMs) when addressing safeguarding concerns surrounding their clients. For the first aim, a narrative synthesis was employed to identify common findings and recommendations across the SARs. The second aim was achieved through the use of a questionnaire with x BICMs and a follow-up interview study with X of the original sample. The review identified key areas of difficultly within current safeguarding procedures; a lack of understanding of brain injury, and its impact of individuals and their families, among social services and local authorities; an absence of interdisciplinarity, information sharing, and communication between services, and failure to assess mental capacity correctly. The final theme was elaborated on in the survey and interview study with the failure being due to 1) a poor understanding of aspects of the mental capacity legislation, particularly surrounding unwise decisions, and 2) a lack of professional curiosity. Both the review and the subsequent study highlight the shortcomings in social work practice, education and training within the UK with regards to brain injury. The research programme provides recommendations to current social work practice and highlights the need for significant improvements in pre-qualification and post-qualification training and supervision of social workers.
236 Perceived social support, resilience and recent life events are associated with persistent post-concussion symptoms after mild traumatic brain injury
Kaisa Mäkia, Taina Nyboa, Marja Hietanena, Susanna Melkasb
aDivision of Neuropsychology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland, bDepartment of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
ABSTRACT
Objective: Most patients recover from a mild traumatic brain injury (mTBI) within days or weeks but a substantial minority experiences symptoms persisting beyond three months post-injury. Persistent post-concussion symptoms (PPCS) are complex and probably multifactorial in origin. The present study examined associations between psychosocial factors and PPCS at three months after mTBI.
Methods: One hundred adult patients (age 18–68 years) meeting the World Health Organization’s Collaborating Center for Neurotrauma Task Force criteria for mTBI were included in the study. Patients were enrolled from consecutive referrals to a TBI outpatient clinic and recruitment took place within 12 days from injury. At three months post-injury, patients completed self-report measures of perceived social support (abbreviated Medical Outcome Study Social Support Survey) and resilience (Resilience Scale-14). Information on recent life events was collected through a structured interview. Self-reported symptoms were assessed with Rivermead Post-Concussion Symptoms Questionnaire (RPQ). PPCS were defined as endorsing ≥ 3 symptoms in the RPQ.
Results: Thirty-three (33%) participants reported 3 or more symptoms, thus meeting the criteria for PPCS. The most frequently endorsed individual symptoms in the PPCS group were fatigue (70%), headaches (55%), and difficulty concentrating (52%). Participants with PPCS reported lower perceived social support (p = 0.003), lower resilience (p = 0.001), and more recent life events (p = .038) than participants without PPCS.
Conclusions: Psychosocial factors are associated with PPCS, and they should be evaluated and addressed in mTBI/PPCS management.
237 Pain responsiveness in patients with disorder of consciousness: an international multicentric study with nociception coma scale-revised with personalized painful stimulation
Dr. Rita Formisanoa, Sara Schiattonea, Marta Aloisia, Giulia Ferria, Anna Estraneob, Alfonso Magliacanob, Steven Laureysc, Olivia Gosseriesc,d,e,f, Marco Iosaa, Aurore Thibautc,d,e,f, Charlotte Maritialc,d,e,f
aIRCCS Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy., Roma, Italy, bDon Carlo Gnocchi Foundation, Scientific Institute for Research and Health Care, Florence, Italy, cComa Science Group, GIGA-Consciousness & Center du Cerveaub, University & University Hospital of Liège, Liège, Belgium, dGIGA Conciousness, Liege, Belgium, eUniversity & University Hospital of Liege, Liege, Belgium, fCentre du Cerveau, Paris, France
ABSTRACT
Introduction: Pain perception in patients with disorder of consciousness (DoC) is still a controversial topic and matter of debate. Nociception Coma Scale (NCS) and its revised form (NCS-r) have been proposed to assess pain responsiveness in persons with DoC, using a standard stimulus, consisting of pressure on fingernail bed. In a previous monocentric study NCS-r with personalized painful stimulation, identified by professionals and caregivers involved in the care and rehabilitation of persons with DoC, obtained higher scores in comparison with the standard stimulus. An international multicentric study was launched by IBIA DoC SIG and is still ongoing. AIM: The aim of the study is to compare the efficacy of a personalized painful stimulus in comparison with the standard one.
Methods: The sample was formed by 31 patients with a mean age of 43.0 ± 15.4 years, 14 females (45%), mean CRS-R score = 9 ± 5, and a mean time from acute event of 112 ± 91 days.
Statistical Analysis: For sake of clarity, data have been reported in terms of percentage relative frequency or mean ± standard deviation also for ordinal scores. Reliability was assessed by a chi-squared test between two different raters. The validity was tested analyzing if the NCS scores were significantly higher (tested using Wilcoxon test) when the stimulus was personalized (PS) with respect to standard stimuli (SS).Spearman coefficient was used to assess correlations. Alpha level was set at 5% for all the analyses.
Results: In 23 patients (74%) a personalized stimulus (PS) was identified as different from the standard stimulus (SS).
The two raters differed just from one patient about the possibility of identifying the PS. For both the raters, no differences in motor responses were noted between PS and SS. The mean score of NCS-r, averaged between the two raters, was significantly higher for PS than SS for verbal responses (0.7 ± 0.9 vs. 0.4 ± 0.7, p = 0.020) and close to significant level for motor (1.5 ± 1.0 vs. 1.2 ± 0.6, p = 0.067) and facial (1.1 ± 1.0 vs. 0.8 ± 0.8, p = 0.095) responses.
The level of reliability between the two raters was for motor responses and facial expression 74% for SS and 78% for PS, and for verbal responses 100% in both the stimuli.
Finally, correlations between NCS-scores (averaged between the two raters) and CRS-R scores assessed at baseline resulted highly significant for motor scores both with PS (R = 0.536, p = 0.007) and SS (R = 0.510, p = 0.011), close to significant level for facial score for PS (R = 0.384, p = 0.064), but not for SS (R = 0.074, p = 0.730), whereas no correlations were found for verbal response scores and CRS-R.
Conclusions: The use of personalized painful stimulus seems to be reliable and could be used at least when no response is obtained with the standard painful stimulation.
This project was funded by European Union’s Horizon 2020 programme (Marie Skłodowska-Curie grant 778234-DoCMA project).
238 Metacognitive strategy training versus psychoeducation for improving fatigue in children and adolescents with acquired brain injuries: a randomized controlled trial
Ruth Hyphera, Anne Elisabeth Brandtb,c, Eva Skovlundd, Anne-Britt Skarbøa, Helene Eidsmo Bardere, Stein Anderssonf, Torstein Baade Røb,c, Kari Risnesb,c, Torun Gangaune Finnangerb, Jan Stubberudf,g
aDepartment of Pediatric Neurology, Oslo University Hospital, Oslo, Norway, bChildren’s Clinic. St Olav’s Hospital, Trondheim, Norway, cDepartment of Clinical and Molecular Medicine, University of Science and Technology, Trondheim, Norway, dDepartment of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway, eFaculty of Health Studies, VID Specialized University, Oslo, Norway, fDepartment of Psychology, University of Oslo, Oslo, Norway, gDepartment of Research, Lovisenberg Diaconal Hospital, Oslo, Norway
ABSTRACT
Objective: The present study aims to explore the relative effectiveness of two group-based cognitive rehabilitation programs for reducing fatigue in pediatric acquired brain injuries (pABI), including brain tumor, traumatic brain injury, cerebrovascular events, hypoxia/anoxia, and brain infections/inflammations.
Methods: This is an exploratory study of secondary endpoints in a blinded, parallel-randomized controlled trial with children and adolescents (ages 10–17 years) in the chronic phase (> 1 year after injury/treatment) of pABI with reported executive dysfunction. It investigates the effectiveness of a metacognitive program (pediatric Goal Management Training, n = 36) compared to a psychoeducational program (pediatric Brain Health Workshop, n = 37) for reducing fatigue (Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale), 8 weeks and 6 months post-intervention.
Results: Seventy-three participants completed the allocated interventions, and 71 attended the 6-month follow-up. The results showed a significant decrease in parent-reported fatigue for both interventions from baseline to the 6-month follow-up. Forty percent of the total sample had a reliable change. There was no significant difference between the intervention groups, but a tendency in favor of the psychoeducational approach. Only subscales cognitive and sleep/rest fatigue showed significant reductions. In regression analyses, several factors predicted fatigue at 6-months follow up, but only better global outcome and executive attention predicted a decrease in fatigue symptoms after 6 months.
Conclusions: Group-based cognitive rehabilitation in the chronic phase of pABI, including education of parents and teachers, may be helpful in reducing fatigue. Global outcome and executive attention at baseline predicted fatigue improvement. Developmental factors are important to consider when tailoring pediatric interventions, as well as modifiable factors associated with fatigue.
239 Long-Term Social Cognition and Behavioral Problems After Subarachnoid Hemorrhage and Their Relation to Participation
Lieke Jornaa, Sara Khosdelazada, Sandra Rakersa, Ralf Koffijbergb, Rob Groenc, Anne Buunka, Jacoba Spikmana
aDepartment of Neurology, Unit Neuropsychology, University Medical Center Groningen, Groningen, The Netherlands, bDepartment of Medical Psychology, Medical Center Leeuwarden, Leeuwarden, The Netherlands, cDepartment of Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
ABSTRACT
Objective: This study aims to longitudinally investigate social cognition and behavior in both aSAH and anSAH patients to determine whether there is recovery of early impairments or whether these persist in the chronic stage. We will investigate whether there is a relation between social cognition and behavioral problems in the chronic stage after SAH, and whether there is a relation with long-term societal participation. This would have large clinical relevance, since it would allow for early identification of patients at risk for diminished long-term societal participation.
Methods: This longitudinal follow-up study included SAH patients who were admitted to the University Medical Center Groningen. Neuropsychological assessments were performed in the subacute stage (3–6 months) after SAH (T1) and again in the chronic stage (2–4 years) after SAH (T2). Emotion recognition was measured using the Ekman 60-Faces test (FEEST), and Theory of Mind (ToM) was measured using the Cartoon Test and the Faux Pas Test. Behavioral problems were quantified using the Apathy Evaluation Scale (AES) and the Dysexecutive Questionnaire (DEX). Of both questionnaires, both a self-rated and proxy-rated version were used. Finally, the Role Resumption List (RRL) was used to assess changes in amount and quality of work, social relations, leisure activities and mobility.
Results: A total of 59 aSAH and 22 anSAH patients were included in this study. For the Cartoon test, a significant improvement was found for aSAH patients at T2. The effect size was small to medium. For the other tests, no significant differences were found over time. Furthermore, significantly more problems on both the DEX-self and DEX-proxy were reported at T2 in anSAH patients. The effect size was large. There were no significant differences on the AES over time in either of the patient groups. A significant negative correlation between the FEEST and AES-I as well as between the Cartoons and AES-I was found in aSAH patients, but not anSAH patients, at T2. Correlations between social cognition tests and societal participation at T2 were not significant. However, the DEX-self, DEX-proxy and AES-S were significantly correlated with both work and societal participation in aSAH patients. For anSAH patients this was the case for the DEX-proxy only.
Conclusions: Social cognition impairments and behavioral problems after SAH seem to persist over time. Moreover, behavioral changes in the chronic stage after both aSAH and anSAH are related to long-term problems in work and societal participation. The findings of the current study emphasize the need for more attention to social cognition and behavior after SAH. This might allow for early identification of patients at risk for diminished long-term participation and may guide a more individualized rehabilitation approach.
240 Rapid firing of a short fuse: dual perceptions of explosive and challenging behaviors in chronic traumatic brain injury
Charlotte Hendryckxa,b,c, Mélanie Coutured, Nadia Gosselinb,c, Mireille Gagnon-Roya,e, Geneviève Thibaulta,f, Emily Nalderg, Carolina Bottaria,e
aCenter for Interdisciplinary Research in Rehabilitation of Greater Montréal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montreal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montréal, Canada, bCenter for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Center de Recherche du CIUSSS NIM, Montréal, Canada, cDepartment of Psychology, Université de Montréal, Montréal, Canada, dCentre for research and expertise in social gerontology (CREGÉS), CIUSSS West Central Montreal, Montréal, Canada, eSchool of Rehabilitation, Université de Montréal, Montréal, Canada, fService québécois d’expertise en troubles graves du comportement (SQETGC), Montréal, Canada, gDepartment of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
ABSTRACT
Introduction: Challenging behaviors are one of the most serious sequelae after a traumatic brain injury (TBI). Their intense and unpredictable nature impacts the lives of people with TBI and their family caregivers. However, the perspectives of these dyads have rarely been explored, while capturing them would help identify more individualized interventions targeted to each of their needs.
Objectives: (1) Compare and contrast the perceptions of family caregivers and people with TBI about behaviors they considered as challenging.
Method: Using a descriptive qualitative design, we interviewed individually each member of dyads (persons with TBI and their caregivers). Interviews were transcribed and analyzed using the inductive approach of Miles, Huberman & Saldana (2014). We then made comparative matrices of individual perspectives within dyads to highlight overlaps and divergences (Eisikovits & Koren, 2010). RESULTS: Fifteen caregivers and 17 people with TBI (21.47 year post-injury on average) were interviewed, accounting for 10 dyads, two triads, and six single participants, for an average duration of 58 minutes. A main theme emerged reflecting how challenging behaviors were characterized: the uncontrollable rapid firing of the short fuse (i.e., difficulty controlling oneself, the sudden and/or explosive presentation of the behavior, and unsafe behavior). Perceptions of the behaviors within dyads were aligned with the presence of verbal and physical aggression (toward self, others or objects), emotional lability, compulsive purchases or substance use/selling. These perceptions were yet uniquely nuanced in the examples/triggers identified. When only one member of the dyad mentioned the behavior, it was often the caregiver. People with TBI talked about aggressive outbursts, but only after its occurrence, and only if they hadn’t forgotten the episode. They also identified feelings of (un)happiness associated with their compulsive purchases. Caregivers identified flat affect as challenging, and many viewed emotional lability as childish rather than a consequence of their brain injury. Participants reported positive change over time for many behaviors, with caregivers stating this, particularly when people with TBI can identify their frustrations and put strategies in place.
Discussion: Our results showed a high degree of agreement between dyads about the challenging nature of explosive behaviors, with a unique perspective of each member of the dyad. It reinforces the critical importance of providing interventions that include both psychoeducation, to help the dyad understand challenging behaviors and how these are associated with the individual’s injury to the brain, and behavioral analysis, to help them identify potential triggers for these challenging behaviors. These two steps would allow the clinician to work collaboratively with the dyads to develop intervention strategies. Individuals with TBI would better anticipate and self-manage their behaviors, which would promote their sense of control over their lives, while caregivers would learn how best to support them and reduce their daily burden.
242 Invisible or visible? The lived experience of adults with an acquired brain injury in Ireland
Lorraine M. Duffya, Jane Sixsmithb
aIndependent Consultant, Galway, Ireland, bUniversity of Galway, Galway, Ireland
ABSTRACT
Introduction: There can be invisible consequences for people who acquire brain injuries, which can impact their lives negatively. These consequences can be physical, cognitive, emotional and/or behavioral. This study explored the lived experience of adults affected by the invisible consequences of acquired brain injury (ABI) and included an exploration of the supports available for brain injury survivors to live their best life.
Methods: The study used a qualitative methodology informed by van Manen’s hermeneutic phenomenological approach. Ten in-depth semi-structured online interviews were undertaken, analyzed and interpreted, using van Manen’s six-step methodological structure as a framework for thematic analysis.
Results: It emerged through the conversations with ABI survivors that there are two sides to the consequences of ABI, both invisible and visible. The lived experience appeared as a type of over-and-back tension or “tug of war,” which included positive and negative outcomes and changes in personality for participants. This tension can lead to frustration for the ABI survivor and their families. An ABI’s consequences significantly impact survivors’ recovery and well-being as they are affected emotionally by both the invisibility and visibility of their consequences. The results indicated that the most common consequences experienced by participants were fatigue and emotional/behavioral, which impacted one another. Social support and counseling were critical supports for survivors in their recovery. Cognitive consequences also impacted participants’ lives to a lesser extent.
Conclusions: ABI’s physical, cognitive and emotional/behavioral consequences can be invisible and visible to the survivor. This invisibility and visibility results in tension between how people see themselves and how others perceive them. The results indicated that ABI survivors in Ireland struggle with the lack of timely access to rehabilitation. Their recovery improves when they begin to receive support from brain injury organizations through a person-centered approach. The invisibility of the consequences of an ABI results in a hidden disability often unrecognized by others due to a lack of awareness and understanding of the life-changing consequences of an ABI.
Keywords: Acquired brain injury, fatigue, lived experience, social support, invisible disability
243 The relationship between persistent COVID-19 complaints, brain damage, and cognitive dysfunction in initially hospitalized patients – results of the prospective multicentre NeNeSCo study
Simona Klinkhammera, Annelien Duitsa,b, Esmée Verwijkc,d, Janneke Horne, Johanna Visser-Meilyf, Arjen Slooterg,h, Caroline van Heugtena,i, the NeNeSCo study group
aDepartment of Psychiatry and Neuropsychology, Maastricht University, Maastricht, Netherlands, bDepartment of Medical Psychology, Maastricht University Medical Center, Maastricht, Netherlands, cDepartment of Medical Psychology, Amsterdam University Medical Center, Amsterdam, Netherlands, dDepartment of Psychology, Brain and Cognition, University of Amsterdam, Amsterdam, Netherlands, eDepartment of Intensive Care, Amsterdam University Medical Center, Amsterdam, Netherlands, fDepartment of Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht, Utrecht, Netherlands, gDepartment of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, Netherlands, hDepartment of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium, iDepartment of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, Netherlands
ABSTRACT
A substantial proportion of COVID-19 survivors experiences persistent consequences, among which cognitive complaints and fatigue. These complaints could be the result of brain damage and cognitive dysfunction. Supporting this, COVID-19 MRI studies commonly report microbleeds and white matter lesions (WML) and neuropsychological studies report cognitive dysfunction. However, studies assessing the relationship between complaints and objective consequences are lacking. Therefore, we investigated whether fatigue and cognitive complaints are associated with higher levels of brain abnormalities and cognitive dysfunction.
Methods: For this large-scale prospective multicentre cohort study, we recruited initially ICU and general ward hospitalized (non-ICU) COVID-19 patients at approximately eight- to ten months post-discharge. Patients underwent a 3T MRI scan that was evaluated for number of cerebral microbleeds and severity of WML (Fazekas scale). An extensive cognitive test battery was completed and resulting multivariate cognitive profiles were compared to normative data. Fatigue and cognitive complaints were measured using the Fatigue Severity Scale and the Checklist for Cognitive Consequences following Intensive Care Admission.
Results: Data of 205 patients (ICU = 101, non-ICU = 104; Mdn age = 63, IQR = 53–69; 70% male) was collected. 62% [122/196] of patients reported ≥ 3 cognitive complaints and 51% [99/195] experienced severe fatigue. Cognitive profiles of 12% [25/204] of patients deviated significantly from age and education-corrected norms. MRI scans of 46.5% (92/198) patients showed cerebral microbleeds, with most patients (66.7% [132/198]) having 1 microbleed but several individuals (7.6% [15/198]) having ≥ 20 microbleeds. Punctuate WML were found in 40.4% [80/198], starting confluent WML in 23.2% [46/198], and confluent WML in 3% [6/198]. Fatigue correlated neither with the number of microbleeds nor with severity of WML (rτ = −0.07, p = 0.21; rτ = 0.03, p = 0.58). The number of cognitive complaints was not associated with microbleeds (rτ = 0.002, p = 0.97) but more cognitive complaints correlated significantly with more severe WML (rτ = 0.13, p = 0.03). Significantly higher levels of fatigue but similar numbers of cognitive complaints were reported by patients with deviant cognitive profiles compared to those with non-deviant profiles (fatigue: Mdn = 45 vs. 36, p = 0.047; cognitive complaints: p = 0.384). Neither number of microbleeds nor severity of WML were significantly associated with cognitive profile deviance (p = 0.96; p = 0.93).
Conclusion: Fatigue severity was not found to be associated with either of the two assessed MRI abnormalities. Patients with more cognitive complaints, despite not having more cognitive dysfunction, had more severe white matter lesions. Fatigue severity was higher among patients with cognitive dysfunction compared to those without. However, the small percentage of cognitive dysfunction in the sample cannot account for such high rates of severe fatigue (12% vs. 51%). These findings suggests that additionally to physiological factors, psychological-, social-, and environmental factors likely play a role in the experience of persistent complaints.
244 Preliminary results of the first pilot of ketamine to treat disorders of consciousness
Paolo Cardonea,b, Arthur Bonhommea,b, Vincent Bonhommec,d, Cécile Staquetc,d, Naji Alnaggera,b, Pauline Ezane, Nicolas Lejeunea,f, Sébastien Van Goethemf, Steven Laureysa,b, Charlotte Martiala,b, Olivia Gosseriesa,b
aComa Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium, bCentre du Cerveau2, University Hospital of Liège, Liège, Belgium, cAnesthesia and Perioperative Neuroscience, GIGA-Consciousness, University of Liège, Liège, Belgium, dDepartment of Anesthesia and Intensive Care Medicine, University Hospital of Liège, Liège, Belgium, eIndependent, Liege, Belgium, fWilliam Lennox Rehabilitation Center, Ottignies-Louvain-la-Neuve, Belgium
ABSTRACT
Introduction: According to recent influential theories of the neuroscience of consciousness such as the “integrated information theory,” consciousness is fundamentally linked to brain complexity. In fact, healthy individuals have high complexity in conscious states (i.e., wakefulness), and low complexity in unconscious ones, either spontaneous (i.e., deep sleep) or pharmacologically induced (i.e., general anesthesia). Similarly, pathological unconscious states such as post-comatose disorders of consciousness (DoC) possess low complexity. Theoretically, increasing brain complexity in these patients should increase conscious level. Critically, recent findings have shown that subanaesthetic doses of ketamine increase brain complexity in healthy participants. Hence, analogous findings in people with DoC could provide a new treatment for DoC.
Methods: We are running a double-blind placebo-controlled pilot study on 3 patients with DoC. Each patient receives either ketamine or placebo on two different days. We use a target-controlled infusion system to control for the dose of intravenous ketamine (maximal concentration of 0.75 µg/ml, reached with steps of 0.15 µg/ml every 10 minutes) and placebo. Simultaneously, EEG is recorded to calculate complexity via Lempel-Ziv complexity (LZC), and consciousness is assessed behaviorally using the Simplified Evaluation of CONsciousness Disorders (SECONDs) scale every 30 minutes. Following the observation of spontaneous decrease of spasticity in the first pilot, we also assess spasticity with the Ashworth-modified score on the four limbs at the beginning and at the end of each session.
Preliminary Results: We have conducted the pilot on two people with DoC. The first patient is a 50yo male individual 7-months post-stroke. He was diagnosed as MCS- at enrollment. The patient presented a linear increase of LZC proportional to the concentration of infused drug, and a decrease during the placebo. We observed a spontaneous decrease of spasticity (not assessed via standardized evaluations) and increased arousal as time spent with eyes open. No new conscious behaviors were observed with the SECONDs. The second patient is a 32yo male individual 13-years post-TBI. He was diagnosed as UWS at enrollment. The patient showed an increase of LZC after infusion and no changes during placebo. Nevertheless, LZC values during ketamine were not higher than the ones in placebo. We observed a decrease in spasticity (assess via the Ashworth-modified score) and increased arousal as time spent with eyes open. A new conscious behavior (response to the command, observed only once) was registered with the SECONDs.
Conclusion: Our pilot demonstrates that ketamine can be safely administered in people with DoC, with the potential of increased brain complexity. Nevertheless, the effects on conscious behavior are so far not clear. Ketamine seems to increase arousal and decrease spasticity. The clinical trial might discover a new use for this substance as an acute treatment for DoC, showing the strength of theory-inspired treatments.
245 Understanding a vital entity of the brain injury care continuum: a survey of how the COVID-19 pandemic impacted community brain injury associations across Canada.
Ana Paula Salazara,b, Carolina Bottaria,b, Sophie Lecoursb, Michelle McDonaldc, Monique A.M. Gignacd,e, Bonnie Swainea,b, Julia Schmidtf, Carolyn Lemskyg, Ashley Brosdah, Lisa Engeld,i
aSchool of Rehabilitation, University of Montreal, Montreal, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montréal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montreal, Canada, cBrain Injury Canada, Ottawa, Canada, dInstitute for Work & Health, Toronto, Canada, eDalla Lana School of Public Health, University of Toronto, Toronto, Canada, fDepartment of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada, gCommunity Head Injury Resource Services of Toronto, Section of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Canada, hBrain Care Center, Edmonton, Canada, iDepartment of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Canada
ABSTRACT
Community brain injury associations are essential to the health and wellbeing of thousands of Canadians living with chronic brain injury and their families/caregivers. Although the over 60 brain injury associations in Canada are often the only support available to brain injury survivors following acute and post-acute brain injury care, they are largely under-funded and under-recognized in the Canadian brain injury care continuum. The COVID-19 pandemic amplified community-based associations’ challenges while also creating new difficulties for brain injury survivors. To describe the experiences of brain injury associations across Canada during the pandemic, an online survey study was conducted in January 2022. Forty-five brain injury associations’ key-representatives from Pacific/Western (n = 18; 40%), Central (n = 25; 56%), and Atlantic Canada (n = 2; 4%) completed the 29 open- and closed-questions about meeting clients’ needs, addressing public health guidelines, and sustaining associations. Data were analyzed using descriptive statistics and qualitative content analysis. Participants were primarily paid executive directors (n = 35; 78%) from brain injury associations with 10 or fewer employees (n = 33; 77%) and serving 100 or more clients (n = 31; 69%) annually pre-pandemic. Social isolation (n = 44; 98%), loneliness (n = 43; 96%), and anxiety (n = 42; 93%) were the most frequently reported psychosocial problems experienced by brain injury survivors during the pandemic. To alleviate these challenges, associations implemented wellness checks and psychosocial support for clients in need. Most respondents (n = 41; 91%) affirmed that clients faced multiple technological barriers, such as lack of computer skills and financial resources for devices and/or internet and discomfort with online activities/programming. To reduce these barriers, brain injury associations provided clients with devices and technology training and helped them apply for cheaper internet and phone services. Community associations also engaged clients in offline activities such as walks and outdoor group meetings when permitted by public health guidelines. Concerning protective measures, thirty (67%) respondents reported clients had challenges understanding and/or following public health guidelines. Forty-two associations (93%) provided tailored information to help clients understand and comply with public health measures. Despite many associations (n = 30; 67%) receiving pandemic-related funding from the Canadian government, brain injury associations still struggled with sustainability. Thirty-four (76%) associations lost funding or financial resources during the pandemic; yet, twenty-eight (62%) observed an increase in demand for programs/services. Overall, brain injury associations across Canada continued to respond to the increasing and varied clients’ needs, while complying with restrictive measures. The pandemic, however, affected associations’ traditional sources of revenue and led to new COVID-related expenses adding further challenges to their sustainability. To ensure community brain injury associations survival, it is essential to aptly recognize the vital role brain injury associations play on the brain injury care continuum and advocate for better funding for them.
246 How community brain injury associations can optimize their response to a future public health crisis: lessons learned after the first year of the COVID-19 pandemic.
Ana Paula Salazara,b, Michelle McDonaldc, Michelle McDonaldc, Lisa Engeld,e, Sophie Lecoursb, Monique M.A. Gignace,f, Shlomit Rotenbergg, Sareh Zarshenasg, Julia Schmidth, Bonnie Swainea,b, Carolyn Lemskyi, Glenda Jamesj, Ruth Wilcockk, Marjolaine Tapinl, Lydia Huardl, Cassandra Stockleym, Gladys Hrabin, Ashley Brosdao, Carolina Bottaria,b
aSchool of Rehabilitation, University of Montreal, Montreal, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montréal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montreal, Canada, cBrain Injury Canada, Ottawa, Canada, dDepartment of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Canada, eInstitute for Work & Health, Toronto, Canada, fDalla Lana School of Public Health, University of Toronto, Toronto, Canada, gDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, hDepartment of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada, iCommunity Head Injury Resource Services of Toronto, Section of Brain and Therapeutics, Department of Psychiatry, University of Toronto, Toronto, Canada, jSaskatchewan Brain Injury Association, Saskatoon, Canada, kOntario Brain Injury Association, Thorold, Canada, lConexion TCC.QC, Montreal, Canada, mNewfoundland & Labrador Brain Injury Association, St. John’s, Canada, nManitoba Brain Injury Association, Winnipeg, Canada, oBrain Care Center, Edmonton, Canada
ABSTRACT
Background: Public health planning is known to not adequately address the needs of people living with disabilities, including those with brain injury. In Canada, brain injury associations provide brain injury survivors and their families/caregivers with long-term support services/programs within the community, positioning them to play an important role in emergency response and fostering inclusion. During the COVID-19 pandemic, community-based associations struggled to respond to the needs of thousands of clients due to gaps in public health guidelines on how to assist people with disabilities. This study documented the challenges faced by brain injury associations during the first year of the pandemic and the lessons learned to optimize their response during future health crises.
Methods: Thirty-two brain injury associations’ key-representatives from seven Canadian provinces participated in seven online semi-structured focus groups. Data were analyzed using a qualitative descriptive thematic approach.
Results: The pandemic worsened associations challenges through loss of traditional revenue sources, new COVID-related expenses, reduced workforce, increased mental health needs of staff, and disruptions in the delivery of support services/programs. Participants suggested some strategies to improve their associations’ response to future health crises: (1) reinforcing disability-based preparedness and making public health resources tailored to support the work of brain injury associations; (2) allocating stable funding sources to provide support for people living with chronic brain injury; (3) supporting staff mental health by offering flexible working conditions to better meet clients’ needs; (4) establishing provincial and national collaborative partnerships with different organizations could allow for faster and effective responses to crisis situations to protect the vulnerable populations; (5) preparing a strong foundation for online services through affordable/accessible devices and/or internet connection and technological computer training for clients; (6) all public health information need to be comprehensive and accurate regarding the role of brain injury associations while acknowledging clients’ realities; and (7) the contribution of associations within the continuum of care and during health crises needs to be recognized.
Conclusions: While facing sustainability challenges, brain injury associations across Canada intensified their efforts and responded to the emerging needs of their clients during the COVID-19 pandemic. Priority preparedness actions in the future were identified as critical to optimize associations’ emergency response and contribute to achieving disability-inclusive lasting changes. According to the World Health Organization, key-stakeholders must take appropriate action to assist in disaster preparedness and alleviate the barriers experienced by people with disability during and after the COVID-19 pandemic. Therefore, it is important to strengthen the collaborative work among brain injury associations across Canada to better support individuals living with brain injury, their families/caregivers. Moreover, it is vital to recognize, support and develop disaster preparedness plans for community-based associations worldwide to improve their resilience and response actions during future public health crises.
247 Evaluation of cedar ABI choices service
Niamh Kennedya, Clair Whitesideb
aUlster University, Coleraine, United Kingdom, bCedar Foundation, Belfast, United Kingdom
ABSTRACT
Introduction: The Cedar Foundation (Cedar) is a leading voluntary organization in Northern Ireland focusing on inclusion for people with disabilities, autism and brain injury. Since 2019 Cedar has delivered an ABI Adult Training & Rehabilitation Service for people with an acquired brain injury called ABI Choices. It aims to support adults with an acquired brain injury to engage in activities in their local community to develop their personal capacity, resilience, health, and well-being.
Aim: This study aims to evaluate the ABI choices service and the impact it had/has on the lives of people with an acquired brain injury and their carers. The study will summarize the outcomes achieved and examine the extent the service met its targets, assessing the extent to which stakeholders’ needs were met.
Method: To gain a holistic, inclusive evaluation of ABI choices, key stakeholders’ opinions were sought from ABI choices service users, staff involved in delivering ABI choices and friends/ family members/carers of service users involved.
A mixed methodology design was employed with three different stakeholder questionnaires (service users, carers and ABI choices staff). These questionnaires had standardized questions regarding the stated aims of ABI choices (for example, increased independence) whilst also allowing free text answers on particular aspects of ABI choices, for example, the perceived strengths of the service. A series of one-to-one interviews were conducted with stakeholders involved in referring to, liaising with Cedar staff, and proving work placements.
Results: Data collection is ongoing. Questionnaires from service users, carers and staff will be collated, analyzed, and their results reported. Qualitative data from interviews will be Thematically analyzed.
Discussion: The extent to which ABI choices impacted the lives of people with an acquired brain injury and their outcomes will be discussed. Capturing recommendations to influence and coproduce future services for people with acquired brain injury, based on evidence-based practice.
248 Canadian brain injury associations responding to clients’ needs during the COVID-19 pandemic: knowledge gained to improve health-related outcomes of the brain injury community
Carolina Bottaria,b, Carolina Bottaria,b, Ana Paula Salazara,b, Sophie Lecoursb, Michelle McDonaldc, Monique A.M. Gignacd,e, Shlomit Rotenbergf, Sareh Zarshenasf, Gladys Hrabig, Lisa Engeld,h
aSchool of Rehabilitation, University of Montreal, Montreal, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montréal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montreal, Canada, cBrain Injury Canada, Ottawa, Canada, dInstitute for Work & Health, Toronto, Canada, eDalla Lana School of Public Health, University of Toronto, Toronto, Canada, fDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, gManitoba Brain Injury Association, Winnipeg, Canada, hDepartment of Occupational Therapy, College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Canada
ABSTRACT
Background: The COVID-19 pandemic created unprecedented challenges for brain injury survivors. This vulnerable population was disproportionately affected by this crisis, due to preexisting disparities and a lack of disability-inclusive response. Brain injury associations in Canada play a vital role in providing healthcare services to the over 1.5 million individuals living with brain injury and their families/caregivers. Since the beginning of the pandemic, brain injury associations witnessed the COVID-19 impacts on brain injury survivors and were at the forefront of responding to their emerging needs. Therefore, key representatives of brain injury associations can provide unique insights into the challenges faced by brain injury survivors during the pandemic. This community-partnership research study aimed to: (1) highlight challenges experienced by brain injury survivors during the pandemic from brain injury associations’ perspective; (2) understand how brain injury associations adapted their services to address clients’ needs; and (3) serve as a basis for preparing initiatives across social and health service providers to promote resilience among brain injury survivors and strengthen brain injury associations’ crisis response.
Methods: Focusing on the first year of the pandemic, we analyzed seven online semi-structured focus groups involving 32 brain injury associations’ stakeholders from seven Canadian provinces using a qualitative descriptive thematic approach.
Results: The main challenges faced by brain injury survivors seeking help from brain injury associations were basic needs insecurities (e.g., food, health, income, and housing), negative impacts on mental health (e.g., isolation, fear around COVID-19), and difficulties complying with public health guidelines. Another key theme was the digital divide: many individuals with brain injury could not use technology mainly due to lack of knowledge and devices and/or financial resources, limiting their access to community and/or governmental support resources. Brain injury associations quickly adapted to meet those needs by: (1) providing essential services related to food, healthcare, and finance; (2) creating new ways to reach out (e.g., wellness checks, door-step deliveries, porch visits) and shifting toward more one-on-one support services; (3) raising awareness about COVID-19 and helping to follow public health guidelines; and (4) pivoting services/programs to online while providing technological devices and training.
Conclusions: The COVID-19 pandemic affected the mental health and safety of thousands of Canadians living with brain injury and highlighted the critical role played by community-based associations in service delivery, particularly regarding alleviating social isolation and accessing government entitlements. Adaptations and innovations in services/programs were identified and included bridging the technology gap and supporting clients to understand and meet public health needs. These findings can facilitate preparedness and collaboration among brain injury associations across Canada to ensure continuity of services after the pandemic and to better protect brain injury survivors in times of public health crises.
249 Evidence of covert higher-order cognitive dysfunctions in critically ill COVID-19 patients with delirium using a multidimensional P3 event-related potentials battery
Fabrice Ferrea,b,c, William Buffièresa, Lizette Heineb, Béatrice Riua, Alexandra Corneyllieb, Benjamine Sartona,c, Stein Silvaa,c, Fabien Perrinb
aIntensive Care Unit, Purpan University Teaching Hospital, Toulouse, France, bCentre de Recherche en Neurosciences de Lyon (CRNL), CAP Team, UCBL – Inserm U1028 – CNRS UMR5292, Bron, France, cToulouse NeuroImaging Center (ToNIC) laboratory, UMR INSERM/UPS 1214, Toulouse, France
ABSTRACT
Accumulating evidence indicates that coronavirus disease 2019 (COVID-19) is a major cause of delirium. Given the global dimension of the current pandemic and the fact that delirium is a strong predictor of cognitive decline for critically ill patients, this raises concerns regarding the neurological cost of COVID-19. Currently, there is a major knowledge gap related to the covert yet potentially incapacitating cognitive impairment underpinning COVID-19 related delirium.
The aim of the current study was to analyze the electrophysiological signatures of the cognitive dysfunctions associated with delirium by using a specifically designed multidimensional auditory P3 event-related potentials battery to probe hierarchical cognitive processes. Clinical variables and electrophysiological data were prospectively collected in controls subjects (n = 14) and in critically ill COVID-19 patients (median age 61 [54.3–72.3] years, sex ratio (M/F): 35/38) with (n = 18) and without (n = 20) delirium. The time from intensive care unit admission to first clinical sign of delirium was of 8 [3.5–20] days and the delirium lasted for 8 [5–10.8] days.
Overall, we have specifically identified in patients with delirium, both a preservation of low-level central auditory processing – notably the detection of local regularity violation (MMN and P3a to local deviant sounds or ‘local effect’) – and a coherent ensemble of covert higher-order cognitive dysfunctions encompassing the processing of global regularity violation (P3b to global deviant sounds or ‘global effect’), simple arithmetic facts violation (P3 to incorrect results), and self-referential stimulus (P3 to subject’s own name) (spatio-temporal clustering, p-cluster ≤ 0.05). In this setting, estimation of the cortical generators of the P3 response to target stimuli by source modeling identified the predominant role of the frontal lobe in control subjects, whose activation was modulated downward by delirium.
While bottom-up automatic attentional functions appeared to be preserved, the top-down voluntary attentional mechanisms required for the active maintenance of stimuli in conscious working memory were impaired in patients with delirium. Interestingly, the cognitive abilities required to categorize self-referential elements of the environment indexing a self-processing and a first-person perspective were also impaired in the event of delirium. These multidomain covert higher-order cognitive impairments involving P3 ERP responses could be due to frontal brain dysfunction. We suggest that our results shed new light on the neuropsychological disorders associated with intensive care unit-related delirium, and may constitute a valuable method for patient’s bedside diagnosis and monitoring in this clinically challenging setting.
250 Thou shalt not kill, but … . the right to die and how to die: some thoughts in light of recent cases of infants with severe brain damage/dysfunction
Esther-Lee Marcusa,b, Yehezkel G. Cainea,b
aHerzog Medical Center, Jerusalem, Israel, bFaculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
ABSTRACT
Over the last decade or so, the issue of life support for seemingly intractable brain-damaged patients has come to the forefront. This is due to technological advances in diagnostics, brain imaging, and life support. Patients who previously would have died from their brain damage are now easily supported for extended periods, either at home or in specialized units. Functional MRI and other diagnostic procedures can show varying levels of brain function in those patients. Consequently, the treating staff has more extraordinary dilemmas to handle, adding to the families’ confusion. Another significant issue is the mingling of cultures, religions, and legal systems with cases crossing borders. Nowhere are the issues more fraught with emotion and confusion than in infants or children. Two recent high-profile cases in the UK brought these issues to the forefront, with the question of continuing or discontinuing life support. The first case was the Charlie Gard case – an 11-month-old infant diagnosed with “Infantile onset encephalomyopathic mitochondrial DNA depletion syndrome” (MDDS). Infants suffering from MDDS typically develop early-onset muscle weakness, rapid progression of symptoms reflecting severe multiorgan dysfunction, followed by death within a short time. When Charlie was diagnosed, he was ventilator dependent. The hospital wished to withdraw life support due to the poor quality of life without a prognosis. The parents wanted to keep him alive and try an experimental treatment. The hospital concluded that this treatment would be futile and may prolong suffering. Charlie’s case was brought to court, and it was decided to withdraw life support. The second case was Alte Fixler, a two-years and four-month-old infant who suffered from a severe hypoxic-ischemic brain injury from birth. Here too, the hospital wished to withdraw life support, whereas Alte’s parents wanted to maintain this treatment, claiming that withdrawing such treatment is not allowed according to their religious beliefs. In an in-depth discussion, the court accepted the hospital’s request to withdraw treatment. Central to such cases are the use of the criteria of “Futility,” “Suffering” and “Best Interest,” with the cultural and religious components confounding the deliberations. These are impacted by the jurisdiction where the deliberations occur. In the UK courts, where the two cases quoted above occurred, the weight given to each differs from other jurisdictions. In Israel, for multiple reasons, it is almost unheard of for a court to approve of active termination of life support. However, they will authorize “non-intervention” when the disease or other complications intervene. In the presentation, we shall discuss the implications of the various approaches and the path we follow in our center.
251 Stroke survivors experience of quality of life, participation and resilience
Marie Matérnea,b, Grahame Simpsonc,d, Gustav Jarlb, Peter Appelrosb, Mialinn Arvidsson-Lindvallb
aUniversity Health Care Research Center, Faculty of Humanities and Social Sciences, Örebro University, Örebro Sweden, Örebro, Sweden, bUniversity Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden, cJohn Walsh Center of Rehabilitation Research, University of Sydney, Sydney, Australia, dBrain Injury Rehabilitation Research Group, Ingham Institute for Applied Medical Research, Sydney, Australia
ABSTRACT
Background: Within a Swedish context, the lived experience of stroke in the acute phase has been documented in a number of studies using a biopsychosocial perspective. However less is known about the challenges in the chronic long-term phase.
Objective: In this study we wanted to explore the lived experience from stroke survivors in Sweden about their resilience and participation, and the relationship between these two constructs and quality of life.
Materials and Method: Kumla is a medium-sized municipality in Sweden in which 330 people living with stroke were identified at the 31st December 2019. A purposive sample of 19 informants were selected based on age, gender, occupation and severity of stroke. Semi-structured telephone interviews were conducted with 10 male and 9 females. The informants were aged between 44–89 years and had lived with their stroke between 1 and 19 years. The interviews were transcribed verbatim and analyzed using qualitative content analysis.
Results: The informants described how the stroke had affected their lives and that they had to ‘adapt life’ due to their stroke. They described their experience as while having found ways to cope with life after stroke, they did not accept the situation. This was captured in the material with an overarching theme; Life with stroke has been adapted to but not accepted. However, the lack of acceptance was explained by some as a resignation, that their lives had changed for good and it has to be accommodated, while others’ experience was one of still working to overcome many of the limitations that they faced. The overarching theme was linked to five sub-themes: 1) Adapting and adjusting to life, 2) Meaningful values in life, 3) Inner resources, 4) Support and treatment from social relations, and 5) Support and treatment from external resources.
Conclusion: Informants explored a tension between adapting to the circumstances and accepting life after stroke. Factors associated with adaptation in life included meaningful values, the informants’ own strategies for adaptation and also support from relationship and society. Resilience strategies were useful, and the contribution of individual, social and societal resources for recovery was important. Quality of life was enhanced both directly and through increased participation.
252 Effect of Wii fit on functional recovery of people with acquired brain injury in the subacute phase at the state reference center for attention to brain damage: a preliminary study
Carlos Abad-Lavaraa, Marta Pérez-Rodrígueza, Carlos González-Altedc, Juan José García-Hernándeza,b
aFundación Segunda Parte, Madrid, Spain, dFrancisco de Vitoria University, Madrid, Spain, cDamage State Reference Center for Brain Damaged Attention (Ceadac), Madrid, Spain
ABSTRACT
Introduction: Acquired brain injury (ABI) is considered the silent epidemic of the 21st century. People with ABI have permanent sequelae in physical, cognitive, behavioral, sensorial, and social fields that can improve mostly in the first year (subacute phase). Including exercise programs in the rehabilitation process, involves great benefits in the goals of the neuro-rehabilitation process. The use of Wii Fit, has proven to be a useful tool in the physical recovery reducing fall risk and is a great option to provide an engaging and flexible form of rehabilitation. This study analyzes the effect of a Wii fit intervention on the functional capacity and risk of fall of patients with ABI of a neuro-rehabilitation center in the subacute phase.
Method: 2 groups were created. Experimental group (EG), 23 console users, 13 males and 10 females. and a control group (CG), 8 users without access, 6 males and 2 females. All CEADAC users. Aged between 26 and 55 years old. Fall risk was analyzed using Time Up and Go (TUG) and 10-meter walk test (10MWT). Fitness is also measured using body mass index (BMI), heart rate and health awareness questions, measured with a Likert scale. Two items are provided by the Wii console, the exercise test’s difficulty, up to 5 points and weight distribution. The evaluation was done before and after the intervention. The pre-study lasted 8 months, during which time EG used the Wii in 30-minute sessions, an average of 25 times. While both groups continued their planned regular rehabilitation program.
Results: No significant differences were observed between groups. Although the averages were compared, improvements were seen in both groups. From health measures, EG improved health awareness by 0.73 points, while CG did not. BMI fluctuations were not observed. EG center of gravity close to 50–50 ideal 1.74% vs CG 1.14%. Heart rate increased 6.5 bpm vs CG 3.88 bpm. Analyzing the Wii test, EG improved by 0.68 in 4 levels, while GC improved by 0.38. Finally, from the physical test, TUG’s EG increased by 1.37s, 10MWT increased by 4.39s, and CG increased by 0.99s and 0.05s, respectively. Discussion: Since this is a preliminary study, it is normal to find no significant differences when comparing the two samples. The effects of Wii can be seen in the recovery of ABI in the subacute phase. Shows improvements in physical and fitness tests.
Conclusions: Improvements in rehabilitation can be observed by using the Wii console. While it is true that larger samples and longer interventions are needed to demonstrate this, we can conclude that the use of Wii as a rehabilitation therapy has positive implications for the physical and emotional recovery of people with ABI.
253 Descriptive analysis of the impact on a physical rehabilitation of people with acquired brain injury in the subacute phase of the use of the socially assistive robots technology
Carlos Abad-Lavaraa, Marta Pérez-Rodrígueza, Carlos González-Altedc, Fuensanta García-Martínd, Pedro Tornero-Almendrosd, José Carlos Pulido-Pascuald,e, Juan José García-Hernándeza,b
aFundación Segunda Parte, Madrid, Spain, bFrancisco de Vitoria University, Madrid, Spain, cDamage State Reference Center for Brain Damaged Attention (Ceadac), Madrid, Spain, dINROBICS, Madrid, Spain, eCarlos III University, Madrid, Spain
ABSTRACT
Introduction: The term Sar Systems (Social Assistive Robots) (1–3) stands for all those robotic platforms that serve or support humans through social interaction, where robots move autonomously in space and actively interact with patients with disabilities for physical improvement. More complete neurorehabilitation can be supported with the use of a SAR system (4–6). To demonstrate this physical improvement in people with acquired brain injury (ABI), upper extremity range of motion (ROM) and trunk control were analyzed at the National Brain Injury Attention Reference Center (CEADAC) (7) in Spain.
Method: 2 groups were created. Experimental Group (EG), 4 users using the robot. and the Control Group (CG), 4 users without access to the bot. 5 males and 3 females, CEADAC users. Aged between 30 and 55 years old. Passive range of motion (ROM) of the elbows and shoulders was measured using a goniometer during various movement and trunk control tests (TCT) (8). Both tests passed before and after intervention. The robot from Inrobics® (9) was used for 6 weeks. EG users had 5 to 7 meetings of 25 minutes each. Both groups continued their usual rehabilitation programs that they had planned. The Inrobics® Active Monitoring System analyzes each session.
Results: Increasing ROM and TCT has no real statistical effect. Goniometric measurements showed improvements in both upper extremity joints in EG compared to CG (0.21% increase in shoulder flexion, 0.71% increase in shoulder abduction, and 2.03% increase in elbow flexion). According to TCT, EG showed a 16% improvement compared to CG 3%. The robot gave us the peak performance improvements of the EG version; 82.09% shoulder flexion, 36.49% shoulder extension, 61.74% shoulder abduction, 117.60% elbow flexion.
Discussion: The objective of this intervention was to test the influence on a physical rehabilitation in an ABI of the SARs technology. A slight improvement in the passive ROM and trunk control of the EG users can be observed (4,6). We agree with previous studies that prove the influence of this on rehabilitation (3,5).
Conclusions: The users of the EG show an improvement in passive movement and body control over those of the CG in all tests. The substantial improvement of the active ROM could be due to the adherence of users to the task, showing greater interest and effort as the sessions progress. Being a very brief intervention, it serves as a starting point to organize a longer one, since it is demonstrated that the users who are subjected to the robot show an improvement and adherence to the task.
254 Can we standardize care pathways for persons with traumatic brain injury? How the healthcare system can help all people get to their best life
Judy Gargaroa, Matheus Wiesta, Mark Bayleya
aKITE Research Institute, Toronto Rehab Institute – UHN, Toronto, Canada
ABSTRACT
Introduction: There are very few jurisdictions worldwide where a clear, comprehensive and integrated care pathway exists for traumatic brain injury (TBI), from the time of injury to long-term living with the condition. Ontario/Canada is no different. Our purpose was to develop an evidence-based, standardized, and integrated pathway for all Ontarians living with TBI of any severity.
Methods: Key stakeholders were convened to develop an evidence-based Ideal Care Pathway for TBI. Stakeholders (n = 101) included people with lived experience, clinicians, researchers, funders, healthcare planners, policymakers and community service providers. Acute, Rehab, and Community Care Working Groups reviewed published literature and clinical practice guidelines to select building blocks for the Ideal Pathway. We focused on key elements (“the what”; e.g., access to primary care), not specific recommendations (“the how”; e.g., hours of therapy) since the latter are the focus of clinical practice guidelines. A fourth Working Group focused on Critical Considerations related to social determinants of health and care planning and provision. Further feedback was obtained from persons with lived experience, marginalized groups, lawyers, and insurers to ensure the Ideal Pathway addressed current gaps in care. Parallel Working Groups developed companion quality indicators and identified the degree to which they were currently being used.
Results: Virtual summits and two sets (2 X 28) of Working Group meetings were held over 5-month periods. The Acute Working Group focused the building blocks on appropriate assessment, initial management and transition planning; the Rehab group on access to specialized rehab, and assessment and planning of community needs; the Community group on community follow-up, mechanisms for re-access and holistic support for patients and families; and all groups on those at-risk. The Critical Considerations Working Group targeted elements poorly covered by current clinical practice guidelines and only partially supported by current healthcare delivery, including social determinants of health, geographic location, marginalized populations, income status, mental health issues, and availability of caregiver support. Further region-specific Working Groups addressed how the Pathway can mitigate regional gaps (i.e., access to specialized service in rural areas), and how and when changes should be implemented. The Ideal Pathway is presented as an interactive web-based diagram that is hyperlinked to clinical practice guidelines, tools, and resources. Twenty-two companion quality indicators have been prioritized to evaluate adherence to key elements in the Ideal Pathway locally and provincially, and administrative data was available for 10 of these indicators.
Conclusions: We have brought together the most comprehensive group of stakeholders to date, importantly including persons with lived experience, funders and government representatives. The evidence-based Ideal Pathway centered around the person with brain injury, has been developed through consensus, with data and clinical strategies to support localized and systemic implementation, to ensure equitable quality evidence-based care after TBI.
255 The effect of fatigue on social life after stroke
Marie Matérnea,b, Olivia Erikssona, Mialinn Arvidsson-Lindvallb, Gustav Jarlb
aUniversity Health Care Research Center, Faculty of Humanities and Social Sciences, Örebro University, Örebro Sweden, Örebro, Sweden, bUniversity Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
ABSTRACT
Background: About 50% of people suffering from stroke also are affected by fatigue. OBJECTIVE: The aim of this study was therefore to investigate to what extent demographic and social factors are associated with stroke survivors’ experience of fatigue.
Material and Method: Data were collected in a Swedish municipality where 330 people living with stroke were identified. They had a mean age of 74.5 years and 42% of them were women. The Fatigue Assessment Scale was used to assess the severity of fatigue. A questionnaire was used to collect data on demographic factors (age, gender, and living conditions) and social factors (having returned to daily life and activities after the stroke, how much of the time the person’s problems had disturbed his/her social activities, and to what extent the person’s problems had disturbed his/her social activities). Severity of fatigue was the dependent variable in the analyses, and the demographic and social factors were independent variables. Univariate linear multiple regression analyses was performed where factors with a p-value less than 0.05 were entered into a linear multiple regression analysis.
Results: In the univariate regression analysis, demographic factors were not significantly associated with severity of fatigue (age p = 0.100, gender p = 0.334, living conditions p = 0.165). All three social factors were significantly associated with severity of fatigue (p < 0.001) and were therefore entered into the multiple regression analysis. In the multiple regression analysis, two factors remained statistically significant: people who had only partly returned to daily life and activities after the stroke (p = 0.005) and those that reported that their problems disturbed them more of the time (p = 0.003) reported more severe fatigue. The extent to which the person’s problems disturbed his/her social activities was not statistically significant in the multiple regression analysis (p = 0.577).
Conclusion: The individual’s participation in social life, both socializing and activities, can thus be seen to have a connection with fatigue, while factors such as gender, age and living situation do not. The study shows the importance of having a holistic perspective on fatigue after stroke, since the phenomenon is complex and cannot be seen to be explained solely by one factor.
256 Implementation of the program “physical activity and sport for acquired brain injury” in people with acquired brain damage in a chronic phase throughout a sports season, 9 months (2021–2022)
Marta Pérez-Rodrígueza, Carlos Abad-Lavaraa, Juan José García-Hernándeza,b
aFundación Segunda Parte, Leganés, Spain, bFrancisco de Vitoria University, Madrid, Spain
ABSTRACT
Introduction: Acquired brain injury (ABI) from both vascular and traumatic causes is a major health issue, being a leading cause of disability. Exercise is a key element in functional recovery and health-related quality of life. The creation of the “Physical Activity and Sport for Acquired Brain Injury” (PASABI) program marked the way to reduce these risks. The aim of this study is to probe the effectiveness of the PASABI program during a whole sport’s season. It consists of different activities designed based on the International Classification of Functioning (ICF) perspective developed by the World Health Organization (WHO). Including water activities, swimming, paddle tennis, initiation to football and initiation to athletics. It includes a first phase with a warm-up exercise (5–10 min of joint mobility tasks) and a second phase with at least three specific analytical exercises and three specific exercises.
Methods: The Program was implemented during the 2021–2022 season in cooperation with the “Fundación Segunda Parte” in Madrid, Spain. A sample of 41 athletes (n = 41) participated in this study. 18 women and 23 men. Aged 22 to 80. These athletes practice from 1 to 6 hours per week (70.7% practiced from 1 to 2 hours, 19.5% from 2 to 4 and 9.8% more than 4 hours) depending on their schedule. To demonstrate the impact of the program, athletes underwent the Berg balance test, Time Up and Go (TUG), 10-meter walk (MWT), and 6-minute walk (MWT). And health awareness questions, measured as: “Poor” = 1; “Adequate” = 2; “Good” = 3; “Very Good” = 4; “Excellent” = 5. These tests were passed at the beginning and end of the season.
Results: Statistics show that there is a significant difference on the Berg test and the 6MWT, with a 56-point improvement of 3.561 in the balance test and an improvement of 24.822 meters in the 6MWT. Also, there seems to be a 0.14 second improvement on TUG and a 0.56 second improvement on 10 MWT. Health awareness questions scores have also improved. The initial average was 2.89 and the 9-month end average was 3.24.
Discussion: Results obtained after one season showing the impact of the Program on the daily life of athletes confirm the above literature. Both balance and physical condition showed significant differences. Fall risk tests improved significantly. The Program also promotes better body awareness by observing each person’s individual vision.
Conclusions: The impact of the Program on the daily life of athletes can be inferred from the analysis of the results, although a larger sample size is required for the fall risk test to identify significant results. By using the PASABI method, it is possible to show physical improvement and one’s own physical vision.
257 Sleep problems and participation restrictions among veterans with mild traumatic brain injury: the mediating role of other post-concussive symptoms
Adam Kinneya,b, Xiang-Dong Yana, Alexandra L. Schneidera, Samuel E. Kinga, Nazanin Bahrainia,c, Jeri Forstera,b, Lisa A. Brennera,d
aVA Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC), Aurora, USA, bDepartment of PM & R, University of Colorado Anschutz School of Medicine, Aurora, USA, cDepartments of PM & R and Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, USA, dDepartments of PM & R, Neurology, and Psychiatry, University of Colorado Anschutz School of Medicine, Aurora, USA
ABSTRACT
Background: Sleep problems are common among Veterans with mild traumatic brain injury (mTBI) and may contribute to participation restrictions. However, explanatory mechanisms underlying this relationship are poorly understood. Sleep problems are associated with post-concussive symptoms (e.g., headaches). In turn, post-concussive symptoms contribute to participation restrictions. We hypothesized that post-concussive symptom severity mediates the purported relationship between sleep problems and participation restrictions among Veterans with mTBI.
Methods: This study was a retrospective analysis of clinical data among 8,733 Veterans with mTBI receiving Veterans Health Administration outpatient care. Sleep problems (yes/no) were identified using the sleep-related item from the Neurobehavioral Symptom Inventory (NSI). Post-concussive symptoms were measured using remaining NSI items. Participation restrictions were measured using the Mayo-Portland Adaptability Inventory Participation Index. We specified a latent variable path model to estimate relationships between: 1) sleep problems and three latent indicators of post-concussive symptoms (vestibular-sensory [e.g., headache]); mood-behavioral [e.g., anxiety]; cognitive [e.g., forgetfulness]); and, 2) the three latent indicators of post-concussive symptoms and two latent indicators of participation restrictions (social and community participation [e.g., leisure activities]; productivity [e.g., financial management]). We examined the indirect effects of sleep problems upon participation restrictions, as mediated by post-concussive symptoms. Estimates were adjusted for sociodemographic factors (e.g., age), injury characteristics (e.g., blast), and co-morbid conditions (e.g., depression).
Results: 87% of Veterans reported sleep problems. Sleep problems were associated with greater social and community participation restrictions, as mediated by mood-behavioral (β = 0.41, p < 0.001) and cognitive symptoms (β = 0.13, p < 0.001). There was no evidence that vestibular-sensory symptoms mediated this relationship (β = −0.01, p = 0.48). Sleep problems were associated with greater productivity restrictions, as mediated by vestibular-sensory (β = 0.16, p < 0.001) and cognitive symptoms (β = 0.14, p < 0.001). There was no evidence that mood-behavioral symptoms mediated this relationship (β = 0.02, p = 0.37).
Conclusion: Findings suggest that evidence-based sleep treatment should occupy a prominent role in rehabilitation of Veterans with mTBI. Indirect effects of sleep problems differed when considering impact on social and community participation versus productivity, informing individualized rehabilitative care for Veterans with mTBI.
258 The effects of rest on concussion symptom resolution and recovery: a meta-analytic review and subgroup analyses of 4329 patients
Anthony Kontosa, Shawn Eaglea, Rock Braithwaitea, Jonathan Preszlera, Rose Turnera, Sabrina Jenningsa, Alicia Trbovicha, Robert Hickeya, Michael Collinsa, Lindsay Nelsona, Michael McCreaa, Jeremy Roota, Danny Thomasa
aUniversity Of Pittsburgh, Pittsburgh, USA
ABSTRACT
Background: There is growing evidence from individual studies that suggests that rest may have a negative effect on outcomes following concussion.
Purpose: Conduct a systematic meta-analysis of the effects of prescribed rest compared to active interventions following concussion.
Study Design: Meta-analytic review
Methods: Meta-analysis (using Hedge’s g) of randomized controlled trials (RCT) and cohort studies evaluating the effects of prescribed rest on symptoms and recovery time. Subgroup analyses were performed for methodological, study, and sample characteristics. Data were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, ProQuest dissertations & theses through May 28, 2021. Eligibility criteria included: 1. Assessment of concussion or mild traumatic brain injury; 2. Included 16 symptoms or days to recovery for at least two timepoints; 3. Two groups with one group assigned to rest; 4. Written in the English language.
Results: 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect (k = 15, g = −0.27, SE = 0.11, 95% C.I. = −0.48, −0.05, P = 0.04) on symptoms, but not on recovery time (k = 8, g = −0.16, SE = 0.21, 95% C.I. = −0.57, 0.26, P = 0.03). Sub-group analyses suggested that studies with shorter duration (<28 days) (g = −0.46, k = 5), involving youth (g = −0.33, k = 12), and those focused on sport related concussion (g = −0.38, k = 8) reported higher effect sizes.
Conclusion: The findings support a small negative effect for prescribed rest on symptoms following concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect. However, the lack of support for an effect for recovery time, and the relatively small numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion.
259 The effects of goal-oriented long-term rehabilitation of persons with acquired brain injury on quality of life after injury
Jasna Vešligaj – Damiša, Veronika Goriseka, Teja Vosineka, Rok Holnthanerb
aNaprej, Center for Persons with Acquired Brain Injury Maribor, Maribor, Slovenia, bUniversity Clinical Center Maribor, Department of Psychiatry, Maribor, Slovenia
ABSTRACT
Background: After completing primary medical rehabilitation, persons who have suffered a severe brain injury most often need appropriate professional help and counseling as well as inclusion in stimulating environment that enables progress, learning and support in finding new life goals upon returning to their home environment and in finding sense in life after severe acquired brain injury. We are talking about a long-term need for psycho-social and health care or about long-term rehabilitation. This is the kind of service that we provide at Center Naprej Maribor. We are a specialized regional center that provides high intensity services of long-term rehabilitation for persons with acquired brain injury (ABI).
Objectives: The aim of our study was to evaluate whether application of an established and goal-oriented rehabilitation program in persons with acquired brain injury can help in setting life goals, finding meaning in life and improving the quality of life.
Methods: Participants: We included 43 persons with acquired brain injury, of which 32,6% women and 67,6% men, average age was 51,86 years. All of the participants are included in long-term rehabilitation program in Center Naprej. The duration of their treatment in Center Naprej is from 1 to 14 years. 39,5% of participants suffered a traumatic brain injury and 60,5% of participants suffered a non-traumatic brain injury.
Measurements: Wheel of life – an internal document of Center Naprej, that is a part of individual rehabilitation plan (Center Naprej, 2018), Quality of Life after Brain Injury – QOLIBRI (Von Steinbuechel et al., 2010) and self-evaluation of rehabilitation goal achievement (Center Naprej, 2019).
Results: The results of our research show a significant effect of treatment provided in Center Naprej on different life areas of the participants (evaluated with the measuring instrument Wheel of Life) (p < 0,01). The interaction between the duration of treatment and the quality of life after brain injury (QOLIBRI), as well as between the duration of treatment and important areas of life (Wheel of life) can also be seen (p < 0,01). There is also a trend toward significance of effect of treatment with the duration of treatment (p = 0,06, eta2 = 0,11). Results also show a slightly greater effect of the treatment in women (assessed with the Wheel of life instrument) (eta 2 = 0,09).
Conclusions: Research evidence supports the significant effects of treatment and the impact of length of treatment on satisfaction with life areas and quality of life of persons with acquired brain injury. The paper summarizes the recommendations and presentation of goal-oriented rehabilitation, which illustrates the usefulness of the proposed theoretical framework in the context of rehabilitation for effective optimization of treatment in setting personal goals and the meaning of rehabilitation of persons with ABI in long-term rehabilitation in the lifelong period after injury.
260 CBIT in hand; a digital health intervention and accessible extension to A&E TBI support
Gerard Andersona
aChild Brain Injury Trust, Nr. Bicester, United Kingdom
ABSTRACT
CBIT In Hand is the first ever digital health intervention for families affected by Childhood Acquired Brain Injury in the UK.
It gives parents and families access to virtual support for childhood concussion, head injury and acquired brain injury (ABI) and reaches professionals who need support and advice around this subject, both at the acute stages of injury and through discharge into community services.
CBIT in Hand provides access to tailored information, at your fingertips, when needed.
It offers a vast range of resources and signposting to relevant organizations and puts the difficult terminology into a more readable and simpler form, for all to understand.
CBIT in Hand serves as an adaptable information portal providing information at every stage of a family’s journey after sustaining concussion, head injury or a TBI.
As a digital health support aid to professionals and families at the acute stage of injury, the digital platform has been rolled out across A&E departments across the UK and is an evidenced based health digital support platform.
261 Personalized neurorehabilitation of post-concussive symptoms using a functional neurology approach: a case series
Igor Dijkersa, Thomas R. van den Hofa
aChiropractie Harderwijk, Harderwijk, Nederland
ABSTRACT
Introduction: Long standing symptoms after mild traumatic brain injury are often referred to as post-concussive syndrome/symptoms (PCS). While most people (70–80%) will recover within several weeks after mild traumatic brain injury (mTBI), a large minority suffers from PCS. Furthermore, recovery trajectories for PCS demonstrate large variability. There can be strong overlap with other diagnoses and perceptions, co-morbidities and psychological variables are of importance for recovery. This complicates optimization of treatment protocols. Despite the diagnostic complexity (mild) neurological dysfunctions can be identified in nearly all PCS patients. Quantifiable biomarkers (e.g. vestibular and oculomotor performance, neurocognitive testing) for PCS have been suggested in recent years. Combining of these quantifications and selecting the relevant indicators for the specific individual is likely to assist in appropriate guidance for neurorehabilitation. In the field of functional neurology the aim is to optimize human functionality from as many cognitive and sensorimotor aspects as possible in order to support overall brain function and dampen the symptomatology. Here we present a case series of 9 patients suffering from PCS. PCS prevented them from attending school or performing their job.
Methods: Neurological dysfunctions and weaknesses were evaluated and treatment was adapted accordingly. Treatments varied in intensity, frequency and content, based on the clinical presentation and in particular the neurological findings. Patients were evaluated neurologically as well as quantitatively relevant for their specific clinical presentation. Righteye™, Binocular Visual Assessment (HTSvision.com), Interactive Metronome™ and C3Logix were used for quantification.
Interventions: treatment and training was personalized and included vestibular rehabilitation, oculomotor training, interactive metronome training, home based coordination and balancing exercises, brain games, cognitive exercises, spinal manipulation, and general lifestyle advise. Intensity of treatment varied strongly between individuals from clinical consultations every 2–4 weeks to intensive in clinic training weeks (5 consecutive days)
Outcomes: Age range: 14–43 years old, 3 males, 6 females. Duration of symptoms post mTBI: 4 months to 12 years. Subjective outcomes: 8 out of 9 (88%) patients were able to return to school/work and sports. Objective outcomes: Binocular fusion in convergence improved up to 950%, saccadic reaction time decreased up to 48%, self-paced saccades improved up to 127%, simple and complex reaction times reduced up to 22%, trail making tests improved up to 30%.
Discussion: Despite the chronic duration of PCS, 88% of patients was able to return to work or school after a personalized functional neurological multimodal rehabilitation program. These subjective improvements went alongside quantifiable objective improvements.
262 Brain injury rehabilitation for the uninsured in the united states: garsvp clinic
Juliet Haarbauer-Krupaa,b, Susan Johnsonb, Dajuandra Eugeneb, Tracey Wallanceb
aDepartment of Pediatrics, Emory University School of Medicine, Marietta, USA, bGA RSVP Clinic, Atlanta, USA
ABSTRACT
Background: Individuals who experience brain injury and are uninsured often do not have access to healthcare services in the United States. Uninsured people are less likely to have regular care and more likely to have negative health consequences, poorer health outcomes, (Medford-Davis et al., 2016) and be discharged home rather than rehabilitation facilities (Wilper et al., 2009). In 2018, the uninsured rate in Georgia was 15.9%, higher than the rate for the U.S. overall. Georgia is one of 12 states that did not expand Medicaid coverage so adults between ages 19–64 without dependent children cannot get Medicaid coverage, and adults with dependents need to make below $7,000 a year. A recent study published by a free clinic in Colorado describes initial efforts of serving uninsured individuals with brain and spinal cord injury, stroke, and amputee populations by conducting a retrospective chart review of 15 individuals served by their clinic. Findings indicated that the majority of patients reported a lack of access to care because of funding barriers, not having a primary care provider, or checkup in the last 3 years. To assist in filling the needs of uninsured individuals who experience a brain injury, the Georgia RSVP Clinic (GARSVP) was established following clinical models in Texas and Colorado.
Methods: Our mission is to provide free outpatient rehabilitation care that maximizes independence, wellness, and community participation. The clinic has been in operation since September 2020, staffed by volunteers who provide services once a month in donated space at a rehabilitation hospital, offer education to clients and their families, and run peer and family Support groups. For clients who cannot attend due to medical or transportation challenges, we have added telehealth services.
Results: From September 2020 – September 2022, we provided care for 40 clients with brain injury: 23 clinic admissions and 17 were provided information/referral services to access necessary healthcare services. Of the first ten who completed the program, 80% either met or exceeded at least one of their individual person-centered program goals after an average of 5.2 clinic visits. Individual stories gleaned from this effort are telling. Those who are injured and do not have insurance in the United States are likely to lose their jobs, housing, and social support. They do not have access to healthcare and needed community services that contribute to optimizing health and wellness outcomes.
Conclusions: A free volunteer outpatient rehabilitation clinic is feasible and can contribute to improved outcomes for uninsured individuals with brain injury in the United States. Lessons learned from uninsured individuals can inform the field about unmet needs to facilitate better access to care.
263 Repetitive traumatic brain injury in the context of intimate partner violence, importance of screening in the elderly psychiatric population
Ilia Humberta
aUniversitary Hospital Strasbourg, Schiltigheim, France
ABSTRACT
Research on the neuropsychiatric sequelae of post-intimate partner violence traumatic brain injuries has been developing particularly since 2019. This is concomitant with an increase in such violence in the context of the covid pandemic. Scales for assessing the severity of repetitive head trauma now exist. A new clinical entity has been observed in this context, acquired brain injury sequelae of repetitive traumatic brain injury and strangulation. This has highlighted the need to assess victims of domestic violence like all patients with head injuries, including cognitive, psychiatric, endocrine, neurological at least. In the same way as in professional and sporting contexts, disabling after-effects are possible, with a marked alteration of quality of life. These repeated head injuries and their sequelae need to be better characterized in the populations concerned. The elderly are a population vulnerable to abuse and whose history of intimate partner violence is not systematically investigated. A retrospective observational study was carried out in 2022 in a geriatric population to evaluate the management of patients with a history of intimate partner violence documented in the liaison psychiatry and outpatient psychiatry departments in a hospital in Nantes, France. Five patients were recruited from the psychiatry unit exclusively. These files were analyzed through the prism of knowledge on the after-effects of repeated head trauma in contact sportsmen. We investigated the duration, frequency and age of the patients at the time of the intimate partner violence, psychiatric symptoms, including depressive disorders, anxiety disorders, suicidal behavior and post-traumatic stress disorder, as well as cognitive complaints and cognitive assessments In each situation, we were able to detail symptoms and reactions to treatment that could have been explained and managed in a way that was adapted to the after-effects of head trauma. As a result, we propose an algorithm of management adapted to the knowledge of repeated head trauma and psychiatric practices in the elderly.
264 Advancing knowledge on alexithymia in civilians and veterans with traumatic brain injury: a traumatic brain injury model systems study
Dawn Neumanna,b, Flora Hammonda,b, Mitch Sevignyc, Jacob Finnd, Daniel Klycee,f, Angelle Sanderg,h, Tamara Bushniki, Jessica Ketchumc, Joyce Chungj, Jennifer Bognerk
aIndiana University, Indianapolis, USA, bRehabilitation Hospital of Indiana, Indianapolis, USA, cCraig Hospital, Englewood, USA, dMinneapolis VA Healthcare System, Minneapolis, USA, eCentral Virginia VA Health Care System, Richmond, USA, fVirginia Commonwealth University Health System, Richmond, USA, gBaylor College of Medicine and Harris Health System, Houston, USA, hTIRR Memorial Hermann, Houston, USA, iNYU Langone Health, New York, USA, jVA Palo Alto Healthcare System, Palo Alto, USA, kThe Ohio State University, Columbus, USA
ABSTRACT
Objectives: Lack of emotional insight (difficulty identifying and describing emotions) is known as alexithymia and is believed to be a common, yet poorly understood problem in individuals with traumatic brain injury (TBI). This study aimed to examine alexithymia correlates with social and emotional functioning, as well as the prevalence and characteristics of individuals with high alexithymia in civilians and veterans one-year after a traumatic brain injury (TBI).
Methods: Participants who were enrolled at 4 civilian and 3 VA polytrauma traumatic brain injury model systems (TBIMS) centers and capable of self-report were approached during their 1-year follow-up for study participation. For this study, data was collected on alexithymia (Toronto Alexithymia Scale-20; TAS-20); emotion dysregulation (Difficulty with Emotion Regulation Scale; DERS); post-traumatic stress disorder (PTSD; PCL-C); perspective-taking and empathic concern (Interpersonal reactivity PT and EC subscales, respectively); anger-affect, aggression, and hostility (NIH Toolbox); and resilience (CD-RISC-10). Other relevant data collected during participants’ 1-year follow-up included anxiety (GAD-7); depression (PHQ-9); participation (PART-O); life satisfaction (SWLS); disability (DRS); and functional independence.
Results: Civilian and VA sites enrolled 195 and 68 participants, respectively. Participants were on average 42-years old and predominately male (civilian: 77%; VA: 90%); White (civilian: 71%; VA: 67%); and had a moderate-severe TBI (civilian: 93%; VA: 73%). Mean alexithymia scores for civilians (mean = 46.2; SD = 13.9) and veterans (mean = 50.5; SD = 11.8) were on par with normative means (mean = 45.57; SD = 11.35). However, 14.4% and 16.2% of the civilian and VA samples, respectively, had high TAS-20 scores (≥1.5 SD above standard norms), suggesting impairments with alexithymia. Higher alexithymia scores were moderately-to-strongly associated with greater hostility, emotion dysregulation, anxiety, depression, and PTSD, as well as lower resilience and life satisfaction for both civilians and veterans. Alexithymia and anger-affect were also moderately correlated in VA participants. Bivariate comparisons, which explored differences in demographic, injury-related, and premorbid characteristics in participants with high versus low-average alexithymia scores, found that the former had higher disability ratings and lower FIM scores at 1-year post-TBI (p’s<0.05; both civilian and VA sites). Also, VA participants with high TAS-20 scores had a greater percentage of individuals who reported prior mental health treatment. No significant differences were observed for sex, age, or race/ ethnicity in participants with high versus low-average alexithymia scores.
Conclusions: This is the largest prospective multi-site TBI study on alexithymia in both civilian and veteran samples with TBI to-date. Higher alexithymia scores were associated with poorer functioning on a variety of emotional and social outcomes. Individuals with high alexithymia had more disability and less independence 1-year post-TBI. Causation cannot be interpreted from these findings. Future studies should explore the role of alexithymia in predicting longer-term socio-emotional outcomes after TBI.
265 Neural mechanisms associated with balance performance in collegiate athletes
Tara Porfidoa, Nicola de Souzab, Divya Jainb, Anna Czykierb, Jaclyn Caccesec, Allison Browna, Carrie Esopenkob
aSchool of Health Professions, Rutgers Biomedical and Health Sciences, Newark, USA, bDepartment of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA, cSchool of Health & Rehabilitation Sciences, The Ohio State University College of Medicine, Columbus, USA
ABSTRACT
Objective: To examine the neural mechanics associated with quiet stance balance in collegiate athletes participating in soccer and limited/non-contact sports.
Methods: Division III National Collegiate Athletic Association soccer and limited/non-contact athletes were recruited for participation. Athletes who reported a history of concussion were excluded (n = 18), resulting in a sample of 77 athletes (33 soccer athletes and 44 limited/non-contact athletes). Neuroimaging and balance assessments were completed prior to the start of the athletic season. Diffusion tensor imaging was used to measure fractional anisotropy (FA) which was calculated for 5 bilateral regions of interest known to be linked to balance responses. Balance assessments were completed using the instrumented Balance Error Scoring System (BESS) from the C3Logix system iPad application. Athletes performed 3 stances on a firm surface: double limb stance firm (BESS 1), single limb stance firm (BESS 2), and tandem stance firm (BESS 3), and 3 stances on a foam surface: double limb stance foam (BESS 4), single limb stance foam (BESS 5), and tandem stance foam (BESS 6). Postural sway was measured using the gyroscope and accelerometer obtained through the C3Logix iPad app to track the movement of the body’s center of gravity, with lower sway indicating better performance. Multivariate partial least squares (PLS) analyses were used to examine the relationship between FA and BESS performance.
Results: Lower sway on BESS 2, BESS 5, BESS 6 in soccer athletes and lower sway on BESS 2 and BESS 4 in the limited/non-contact athletes was associated with higher FA in the corticospinal tract (CST), medial lemniscus (ML), inferior cerebellar peduncle (ICP), and right superior cerebellar peduncle (SCP), (p < 0.001, accounting for 73.26% of the cross-block variance).
Conclusions: Better quiet stance balance performance was associated with more intact white matter integrity in the CST and cerebellar tracts in both the soccer and limited/non-contact athletes for several of the BESS stances. However, the pattern of white matter integrity correlated with different BESS stances dependent on sport group. Specifically, only soccer athletes demonstrated this relationship during the most challenging stances (BESS 5 and BESS 6), while only limited/non-contact athletes demonstrated with relationship with BESS 4. This suggests that the neural mechanisms associated with quiet stance balance may differ depending on both the challenge of the task as well as an athlete’s sport specific balance exposures. Thus, sport specific balance exposures may contribute to the neural strategies utilized during quiet stance sensorimotor tasks.
266 Effectiveness of a combined cognitive and vocational intervention on self-reported cognitive symptoms after mild-to-moderate TBI: a randomized controlled trial
Emilie Isager Howea, Silje C. R. Furea, Cecilie Røea,b, Marianne Løvstada,b, Nada Andelica,b
aOslo University Hospital, Oslo, Norway, bUniversity of Oslo, Oslo, Norway
ABSTRACT
Background: Self-reported cognitive symptoms are associated with emotional and somatic complaints and poorer outcomes following mild and moderate traumatic brain injury (TBI). Slowed thinking, memory and attention problems may affect the ability to resume pre-injury activities including work and social life. This warrants clinical studies combining strategies to compensate for cognitive symptoms and rehabilitation efforts to support return to work.
Aims: To compare the effectiveness of a cognitive and vocational rehabilitation program to multidisciplinary treatment as usual (TAU) on self-reported cognitive symptoms up to 12 months after mild-to-moderate TBI.
Methods: We performed a parallel-group randomized controlled trial at a TBI outpatient clinic at Oslo University Hospital, Norway. One hundred sixteen patients with mild-to-moderate TBI aged 18–60 were randomized (1:1) to receive either group-based compensatory cognitive training and supported employment (CCT-SE) (n = 60) or TAU consisting of individualized multidisciplinary treatment (n = 56). Self-reported cognitive symptoms were measured with the cognitive subscale on the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). The subscale contains three items (forgetfulness, poor concentration, taking longer to think) measured on a 5-point Likert scale (from 0 = not experienced at all to 4 = a severe problem). Outcomes were measured at baseline (2–3 months after injury), 3, 6 and 12 months after study inclusion. Between-group differences were analyzed using linear mixed effects models.
Results: There were no significant differences between the intervention and control groups regarding age, gender or proportion with intracranial injuries. The majority of participants (94%) had sustained a mild TBI. At baseline, the mean (95% CI) RPQ cognitive subscale score was 6.8 (5.9, 7.6) in CCT-SE and 5.5 (4.6, 6.4) in TAU. At 12 months follow-up, the mean (95% CI) RPQ subscale score was 4.3 (3.2, 5.3) in CCT-SE and 4.6 (3.5, 5.7) in TAU. At 3 months follow-up, the between-group difference approached significance (P = 0.06). There was a significant between-group difference from baseline to 6 months (mean between-group difference 1.6; 95% CI 0.4, 2.8; P = 0.009) and from baseline to 12 months (mean between-group difference 1.6; 95% CI 0.3, 3.0; P = 0.020), showing a greater improvement in the CCT-SE group compared to TAU.
Conclusions: Cognitive symptom burden declined in both intervention and control group over 12 months. There was a significantly larger improvement in the CCT-SE group compared to TAU indicating a positive effect of compensatory cognitive training in combination with vocational rehabilitation on self-reported cognitive symptoms after mild-to-moderate TBI.
267 Mental fatigue after traumatic brain injury: different determinants across the severity spectrum
Sandra Rakersa
aUniversity Medical Center Groningen, Groningen, Netherlands
ABSTRACT
Objective: Fatigue is a frequent complaint after traumatic brain injury (TBI), irrespective of severity. We aimed to identify factors that contribute to mental fatigue in various severities of TBI by investigating the influence of impaired information processing, mental distress and coping styles.
Method: In a retrospective chart review study, patients with mild (n = 56), and moderate-severe TBI (n = 25) were included, as well as a group of healthy controls (HCs; n = 30). Neuropsychological assessment in the sub-acute to chronic phase after injury consisted of tests requiring information processing speed and questionnaires for fatigue, anxiety, depression and coping styles.
Results: In the moderate-severe TBI group, worse performances on three measures for basic and complex information processing speed were significantly correlated with higher levels of subjectively reported mental fatigue (correlations ranging from 0.40 to 0.50), but not to physical fatigue. In the mild TBI group, information processing speed and mental fatigue were not significantly related. However, presence of anxiety, depression and use of passive coping did significantly positively correlate with mental fatigue in this group (correlations ranging from 0.39 to 0.53).
Conclusions: Important differences in determinants of mental fatigue across the TBI-severity spectrum exist. Slower information processing in moderate-severe TBI is likely to pose a higher cognitive load in demanding (task)situations, which in turn relates to higher levels of mental fatigue. In contrast, reported mental fatigue in case of mild TBI appears strongly associated with mental distress and passive coping. These findings provide different targets for treatment when severity of injury is taken into account.
268 Development and implementation of evidence-based recommendations for rehabilitation in the subacute phase after traumatic brain injury at sunnaas rehabilitation hospital
Angelina Sergeevaa, Solveig Haugera,b,c, Martin Matrea,b,c, Caroline Ustvedta, Anne-Margrethe Linnestadb, Anne-Marthe Sandersb, Gunn Marit Tobiassena, Marianne Løvstadb,c
aDepartment of Traumatic Brain Injury, Sunnaas Rehabilitation Hospital, Nesodden, Norway, bDepartment of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway, cDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
ABSTRACT
Sunnaas Rehabilitation Hospital (SRH) is the largest rehabilitation hospital in Norway and offers multidisciplinary rehabilitation to patients with complex functional impairment following illness or injury. The department of traumatic brain injury (TBI) has 16 beds and offers evidence-based rehabilitation for patients with TBI from South-East Norway (population: 3,1 million) in the subacute phase. National guidelines for rehabilitation after TBI are lacking in Norway. SRH has therefore decided to establish evidence-based recommendations for rehabilitation of TBI patients within three rehabilitation programs: 1) disorders of consciousness (DoC), 2) post-traumatic confusional state (PTCS) and 3) patients with severe cognitive and physical impairment. The work was conducted by a group of leading interdisciplinary clinicians and rehabilitation researchers at SRH. Initial recommendations were established in 2013 and revised in 2022. The document aims to integrate the best available research evidence with clinical expertise and patient values, and to write the recommendations clearly and with clinical relevance, enabling clinical implementation. Throughout the review process parts of the recommendations have been discussed with international TBI experts. The recommendation is a comprehensive 52-pages document, excluding references and enclosures. It includes a summary of evidence and overall rehabilitation principles for each of the three rehabilitation programs, as well as overarching principles that govern our approach to rehabilitation, such as a holistic rehabilitation approach including caregiver involvement and goal orientation. Based on the review of the existing knowledge base, the recommendations are in the process of being further operationalized into step-by-step procedures which are integrated in the rehabilitation programs at Department of TBI. The establishment of distinct procedures is done by the interdisciplinary rehabilitation team of clinicians, working at the Department of TBI. Involvement of clinicians in this part of implementation ensures ownership and engagement by all parties of the clinical team, in turn increasing adherence to established rehabilitation procedures. We consider this work an example of knowledge translation and implementation, and of a fruitful collaboration between researchers and clinicians that clearly enhances the quality of our rehabilitation services. At the conference, a more detailed presentation of the content of the recommendations will be presented.
269 Specialist acquired brain injury (ABI) UK social workers’ (SW) experience of their professional education, and views upon training and education needs of sw’s who work with individuals affected by ABI
Mark Hollowaya, Alyson Normana
aHead First, Hawkhurst, United Kingdom
ABSTRACT
UK SW’s encounter individuals and families affected by ABI in the course of their work. SW’s play a significant role in upholding rights and implementing laws relating to mental capacity and safeguarding; and are gatekeepers to potential resources and sources of support. A growing body of evidence has identified difficulties in SW practice and potential gaps in SW training which have had significant impact on the lives of people with ABI. A UK based team of academics and practitioners working on the ‘Heads Together’ project is researching SW training and knowledge of ABI to better inform future pre and post qualifying course design and content. As part of this programme of research, 10 UK based SW’s with significant experience of ABI have been interviewed to identify themes, and seek views on remedies for difficulties and to describe the contribution SW may make. A narrative synthesis was employed to identify common findings and recommendations. The synthesis identified key areas of difficultly with 1) an absence of training relating to ABI in SW pre-qualification; 2) a lack of interdisciplinarity to better inform practice; 3) the unique value SW can bring when supporting individuals with an ABI; and 4) the flaws and manifest risks that relate both to an absence of basic knowledge of ABI and a failure to work alongside other disciplines. The findings from this study will go on to inform the content of a training programme for SW’s in the UK who are working with those with ABI and their families.
273 Role of sex and pubertal development on anxiety following concussion in adolescents
Anthony Kontosa, Dean Gomesa, Joao-Paulo Lima Santosa, Alicia Trbovicha, Bindal Mehmela, Ted Albrechta, Michael Collinsa, Amelia Versacea
aUniversity Of Pittsburgh, Pittsburgh, USA
ABSTRACT
Background: Up to 30% of adolescents experience anxiety following concussion. Although both female sex and early pubertal development are associated with increased anxiety among adolescents, researchers have yet to examine the role of these factors on anxiety following concussion.
Purpose: Examine the role of sex and pubertal development on anxiety following concussion in at-risk adolescents.
Study Design: Prospective cohort study of adolescents with concussion and uninjured, healthy age and sex-matched controls.
Methods: 109 adolescents aged 12–18 years (43% female) participated in the study including 76 within 3.5 ± 1.7 days of a diagnosed concussion and 33 uninjured, healthy, age and sex-matched controls. All participants were part of the Investigating Concussion in Adolescents at Risk for Emotion dysregulation (iCARE) study (R01MH11488101; PIs: Versace, Kontos) study. Participants provided demographic data and completed the Pubertal Development Scale (PDS), which was used to assess pubertal status with total scores ranging from 1–5. Both concussed and control participants also completed the 41-item Screen for Child Anxiety and Related Disorder, Child Version (SCARED-C) at enrollment into the study. The SCARED-C comprises panic, general, separation, social, school avoidance, and total anxiety scores. Adolescents with a concussion completed the SCARED-C again at 3-weeks and 3-months following injury. Groups were compared on age and PDS using independent samples t-tests and sex using chi-square analysis. One way ANOVA was ten used to compare concussed to controls, with a general linear model (GLM) to examine changes in SCARED-C scores for concussed adolescents across the three time periods in relation to sex and pubertal development.
Results: Groups were similar on age, sex, and PDS total scores. Results from the ANOVA supported significantly higher SCARED-C total (p = 0.02) and subscale scores for concussed compared to uninjured controls. The overall GLM model was significant (F = 2.37; df = 10; p = 0.025) and supported a within-subjects interaction between sex and PDS across time for SCARED-C total scores (p < 0.001). The interaction effect of sex and PDS supported higher SCARED-C total scores for females across all three timepoints (p < 0.001–0.02). Regarding SCARED-C subscales, females reported higher SCARED-C panic symptoms at 3 months (p = 0.02), as well as general anxiety and social anxiety symptoms across all three timepoints (p < 0.001-p = .01).
Conclusion: The findings support elevated levels of anxiety in concussed adolescents compared to uninjured, healthy controls, as well as elevated levels of post-concussion anxiety in females. Following concussion, females with advanced pubertal development reported higher levels of anxiety than males. Clinicians should be aware of the combined role of sex and pubertal development on specific types of anxiety following concussion in adolescents to inform more appropriate interventions for females and males across the developmental span.
274 Cognitive functioning following acute concussion in the general population: the Toronto concussion study
Paul Compera,b,e, Tharshini Chandraa, Evan Fostera, Laura Langera, Lesley Ruttana, Catherine Wiseman Hakesa, Elizabeth Innessa,d,e, George Mochizukia,c,e, Mark Bayleya,e
aToronto Rehabilitation Institute – University Health Network, Toronto, Canada, bUniversity of Toronto – Faculty of Kinesiology and Physical Education, Toronto, Canada, cYork University – School of Kinesiology and Health Science, Toronto, Canada, dUniversity of Toronto – Department of Physical Therapy, Toronto, Canada, eUniversity of Toronto – Rehabilitation Sciences Institute, Faculty of Medicine, Toronto, Canada
ABSTRACT
Concussion is a frequently occurring type of mild traumatic brain injury often resulting in one or more somatic, cognitive and psychological symptoms, and dysfunction. The Hull-Ellis Concussion Clinic at the Toronto Rehabilitation Institute is a rapid access clinic for adults referred from 6 local hospital EDs. In addition to standard of care, adults with acute concussion can engage in a prospective research program at regular intervals over 12 weeks. Extensive data, including assessment of cognitive functioning are collected prospectively. Previously (2017) we reported that objective cognitive scores in a sample of adults with concussion (n = 112) using a norms-based approach yielded ambiguous results; most participants had only mild subjective neurocognitive complaints 1–2 weeks post-injury and very few exhibited objective impairments (i.e., lower than the 3rd percentile). We concluded that neuropsychological tests thought to be sensitive to mTBI were unlikely to be clinically meaningful in isolation. Presently, we describe two studies. Study 1 expands on the work described in 2017. 2236 adults between 17 and 85 years of age have received Clinic-based concussion management since 2016. 473 have participated in the longitudinal study (287 = Females, 186 = Males). The average age is 33.4 years (12.7 SD). Subjective cognitive complaints were characterized by SCAT scores for the 4 cognitive-related domain items. Objective neuropsychological measures as per the NIH Toolkit included Trails A & B and Symbol Search administered at weeks 1, 2, and 12. A measure of verbal learning and recall (RAVLT) and Digit Span (F&B) were administered at Weeks 2 and 12. Scores placing at or below the accepted normative cut-point of the 3rd percentile on any measure were classified as ‘impaired.’ 113 (31%) participants reported an overall SCAT symptom severity score as ‘mild’; 185 (51%) as ‘moderate’; 63 (17%) as ‘severe.’ However, the majority of participants rated the cognitive-specific SCAT items as ‘mild’ at Week 1. When using the 3rd percentile as the accepted cut point reflecting cognitive impairment, only 6 participants (1%) met this criterion. Most participants who endorsed ‘severe’ subjective cognitive disturbance on the SCAT performed better than expected on the various objective measures. These results are similar to those reported previously. Objective cognitive test scores using a norms-based approach were insensitive to determine cognitive ‘impairment’ related to concussion. Study 2 presents the preliminary results of a case control series using 10 adults with acute concussion and 10, non-injured control participants. All participants were administered the same NIH neuropsychological tests described above, at the same time points. Concussed participants showed the same pattern of ‘non-impairment’ as the much larger sample in Study 1. As expected, while non-injured controls showed no indication of objective cognitive impairment, the majority showed greater improvement on all tests at comparative time points relative to concussed participants.
275 Benefits of a 5-week intervention programme in bushcraft skills in a forest school: a novel approach to improve well-being in children with special educational needs and neuro-disability attending an area resource provision
James Tonksa,b, Harriet Dismorec
aHaven Clinical Psychology Practice., Bude, United Kingdom, bUniversity of Exeter Medical School, Exeter, United Kingdom, cPlymouth Institute of Education, University of Plymouth, Plymouth, United Kingdom
ABSTRACT
Previous research indicates that outdoor learning programmes are a beneficial educational approach, but studies have neglected to consider how well this approach may address the social and emotional mental health needs of children with neuro-disability and additional learning needs/ SEND. In this study seven Key-Stage 3 children with neuro-disability from an Area Resource Provision attended a five-week ‘bushcraft’ programme. Standardized psychometric measures of self-concept were completed by the children before and after the intervention, and teachers rated pupils stress levels before and after. Results were analyzed comparing whole group averages and individual change indices. There was convergence of results to support the position that the programme of activity used in this study did convey personal, social, and emotional benefits for this cohort. We advocate that there is a need for further research in establishing how well findings reported here can be replicated and generalized to the wider population of children with neuro-disability and neuro-diverse needs.
276 Symptom catastrophizing is associated with discrepant subjective and objective cognitive functioning after mild traumatic brain injury
Ms. Shuyuan Shia, Mathilde Riouxa, Edwina L Picona, William Panenkab, Noah D Silverberga
aDepartment of Psychology, University Of British Columbia, Vancouver, Canada, bDepartment of Psychiatry, University Of British Columbia, Vancouver, Canada
ABSTRACT
Background: Persistent cognitive symptoms after mild traumatic brain injury (mTBI) often do not match objective cognitive performance. Catastrophizing (i.e., rumination, magnification and helplessness thinking about symptoms) may amplify psychological distress and heighten the discrepancy between subjective and objective cognitive functioning. We hypothesized that symptom catastrophizing will be associated with higher cognitive symptom reporting relative to neuropsychological test performance in patients seeking treatment for mTBI.
Method: The study is a secondary analysis of baseline data from a randomized controlled trial (ClinicalTrials.gov: NCT03972579). Adults with mTBI (N = 77) were recruited from two outpatient mTBI clinics in British Columbia, Canada. Questionnaires and assessments were administered at clinic intake (M = 18.1 weeks post-injury). The sample was 64% female with a mean age of 42.0 years (SD = 11.5). Validated questionnaires were used to assess catastrophizing (Symptom Catastrophizing Scale), cognitive symptoms (Cognition subscale from Rivermead Post Concussion Symptoms Questionnaire; RPQ-Cognitive) and affective distress (combined score on Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2). Objective cognitive functioning was assessed with the National Institutes of Health Toolbox Cognition Battery (NIHTB-CB) fluid cognition composite. Discrepancies between cognitive symptoms and objective cognitive functioning were operationalized by standard residuals with NIHTB-CB fluid cognition composite regressed on RPQ-cognitive.
Results: In a generalized linear model, symptom catastrophizing was associated with worse cognitive symptoms, when controlling for objective cognitive functioning (β = 0.46, 95%CI [0.25,0.67], p < 0.001). In a second model, symptom catastrophizing was also associated with higher subjective-objective cognition residuals (β = 0.45, 95%CI [0.25,0.66], p < 0.001). Catastrophizing remained a significant predictor in both models after affective distress was introduced as a covariate (β = 0.34, 95%CI [0.05,0.63], p = 0.022; β = 0.33, 95%CI [0.04,0.62], p = 0.025). Affective distress was also positively associated with cognitive symptom severity (β = 0.29, 95%CI [0.02,0.56], p = 0.034) and subjective-objective cognition residuals (β = 0.30, 95%CI [0.03,0.57], p = 0.032). The symptom catastrophizing x affective distress interaction terms were not significant.
Discussion: Catastrophizing was associated with misperceptions of cognitive functioning following mTBI, specifically, overreporting cognitive problems relative to objective cognitive functioning. Clinicians should consider catastrophizing in assessment and treatment of persistent cognitive symptoms following mTBI.
277 Impact of mechanism of injury on early outcomes for pediatric patients with disorders of consciousness (DOC) following acquired brain injury during inpatient rehabilitation
Robyn Howartha, Laura Blackwella, Eric Semmela
aChildren’s Healthcare of Atlanta, Atlanta, USA
ABSTRACT
Objective: Disorders of consciousness (DOC) may occur following an acquired brain injury, including coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), and minimally conscious state (MCS). Diagnostic criteria have been previously established, primarily with adults. The aim of the current study is to examine recovery of consciousness amongst pediatric patients with DOC following acquired brain injury who require inpatient rehabilitation. Differences in trajectory and outcomes were examined to determine whether mechanism of injury (traumatic brain injury [TBI], anoxic, other etiology) predicted different consciousness states (VS/UWS vs. MCS vs. CS) at discharge.
Participants & Methods: 45 patients were identified with DOC (VS/UWS or MCS) between the ages of 2–18 years or age (53% female; mean age = 11.6 ± 5.2 years) who received inpatient rehabilitation following a severe brain injury over a 1-year period. Mechanism of injury included traumatic brain injury (TBI; n = 25, 56%), anoxic brain injury (Non-TBI Anoxic; n = 10, 22%), and brain injury by other etiology (Non-TBI Other; n = 10, 22%). Level of responsiveness was serially assessed using the Coma Recovery Scale, Revised (CRS-R), with higher scores reflective of higher levels of awareness and responsiveness.
Results: Average length of stay was 43.6 days (range = 8–71). Patients who sustained a non-traumatic brain injury were significantly younger than those who sustained a TBI. Group differences were also noted with regard to DOC status. 90% of Non-TBI Anoxic patients were in VS/UWS at admission compared to 68% and 60% for TBI and Non-TBI Other, respectively. At discharge, over half of all patients improved in DOC status, with 33% emerging from MCS. Patients in the TBI group had the largest percentage of children who emerged to a conscious state (CS; 52%) compared to the non-traumatic etiology groups (0% Non-TBI Anoxic; 20% Non-TBI Other). Linear mixed models showed a significant increase in CRS-R scores across admission for the TBI and Non-TBI Other groups whereas the Non-TBI Anoxic group displayed a small slope and flat recovery pattern. History of craniotomy, seizures, and VS/UWS at admission significantly predicted CRS-R score trajectory during inpatient rehabilitation.
Conclusions: Previous research investigating the recovery of consciousness and early predictors in pediatric DOC during inpatient rehabilitation is limited. Patients admitted in DOC showed improvements in cognitive status at discharge, with three patterns of recovery emerging that coincided with mechanism of injury. The TBI group had a larger proportion of patients who emerged to a CS. The non-TBI Other group was more likely to recover compared to anoxic but less than TBI etiologies. Patients who sustained an anoxic brain injury displayed minimal to no change in DOC status during admission. Current findings emphasize the impact of mechanism of injury on early recovery and the need for serial monitoring using standardized assessments to help impact care strategies.
278 Metacognition and functional cognitive symptoms after concussion
Edwina Picona, Rebecca Todda, Daniela Palomboa, Noah Silverberga
aUniversity Of British Columbia, Vancouver, Canada
ABSTRACT
Introduction: Memory complaints after concussion are largely unrelated to injury severity, objective memory performance, or neuroimaging findings, and may be a manifestation of a Functional Cognitive Disorder (FCD; cognitive symptoms not attributable to brain injury/disease). Metacognition, the ability to judge and reflect upon one’s cognitive processes, has been proposed to underlie FCD. The current study explores how metacognition might be involved in the development of FCD after concussion.
Methods: In a cross-sectional study of 54 participants (n = 34 with concussion and n = 20 healthy controls), subgroups were formed based on FCD symptom severity to compare participants with suspected FCD after concussion (n = 28) and healthy controls with no concerns about their memory (n = 13). Participants completed a set of computerized tasks with 2-alternative-forced choice recognition memory or perceptual judgments (“Which of these two words did you see earlier?” or “Which of these two words is brighter?”) and Likert scale confidence ratings (“How confident are you that you answered correctly?”) on each trial. The perceptual task was included in order to test for a memory-specific metacognitive deficit over and above domain-general metacognitive impairment. These tasks yield measures of metacognitive bias (i.e., the degree to which confidence ratings discriminate between correct and incorrect trials while controlling for task performance) and confidence (average confidence ratings). FCD symptom severity was measured with the Functional Memory Disorder Inventory – Long Version, which asks participants to rate the frequency with which they experience universal/benign memory lapses (e.g., blanking on a password or a person’s name). Independent sample t-tests compared the two subgroups. Linear regressions tested the relationship between metacognitive memory bias and FCD symptom severity in the full concussion sample.
Results: There was no significant difference between groups (suspected FCD after concussion vs. healthy controls) in metacognitive bias (t = −0.70, Cohen’s d = −0.23, 95% CI: −0.89–0.43) or memory task confidence (t = 0.16, Cohen’s d = 0.05, 95% CI: −0.60–0.19). In the full concussion sample, neither metacognitive bias (B = 8.36, 95% CI: −7.53–24.25) nor memory confidence (B = 3.08, 95% CI: −16.78, 22.94) were associated with FCD symptom severity. The perceptual metacognitive variables did not differ between groups and were not associated with FCD symptom severity.
Conclusion: Taken together with recent studies similarly reporting a lack of association between indicators of local (within-task) metacognition and FCD, the present findings suggest that impaired metacognition is an unlikely candidate for explaining FCD after concussion. Future research should focus on other potential predisposing and perpetuating factors in theoretical models of FCD.
279 Optimizing recovery during subacute physical rehabilitation in children and adolescents with acquired brain injury: an expert consensus statement using a Delphi approach
Christiaan Gmelig Meylinga,b,c, OV Verschurena, IR Rentinckb, JW Gortera,d,e, RHH Engelbertf,g,h
aUMC Utrecht Brain Center and Center of Excellence for Rehabilitation Medicine, Utrecht University, Utrecht, The Netherlands, bDepartment of Pediatric Rehabilitation, De Hoogstraat Rehabilitation, Utrecht, The Netherlands, cHU University of Applied Sciences Utrecht, Institute of Human Movement Studies, Master Pediatric Physiotherapy, Utrecht, The Netherlands, dDepartment of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands, eDepartment of Pediatrics, CanChild Center for Childhood Disability Research, McMaster University, Hamilton, Canada, fDepartment of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, gFaculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands, hDepartment of Pediatrics, Amsterdam UMC, Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
ABSTRACT
Background: Physical rehabilitation programs after acquired brain injury (ABI) in children and adolescents have great potential to improve recovery through experience-dependent neural plasticity, in which dosage of practice is an important component. However, it is unclear how optimal physical intervention characteristics should look like during the subacute phase. The aim of this Delphi study was to develop a consensus statement among international experts regarding recommendations on physical rehabilitation in children and adolescents with ABI during the subacute phase.
Methods: A three-round Delphi study was performed. Eleven international experts in rehabilitation and/or research in children and adolescents with ABI agreed to participate, of which two were supported by a multidisciplinary team. The individual experts had a profession in pediatric neurology, pediatric rehabilitation medicine, nursing, physiotherapy, occupational therapy and neuropsychology. During round 1a and 1b, the experts shared their ideas and experiences through a series of open-ended questions. The responses were formatted into 139 statements. Subsequently, statements were rated on a 5-point Likert scale for importance (from 1 = not important to 5 = very important) in round 2. Median and interquartile ranges (IQR) Likert scores were calculated. Finally, statements that did not reach consensus were reranked by the panel in round 3. The main outcome was consensus agreement, defined a priori as a median Likert-score ≥4 and IQR ≤1.
Results: The response rates were 100% for round 1a, 91% for round 1b, 91% for round 2 and 100% for round 3. After round 2, consensus was reached on 73/139 statements (53%). After round 3 consensus was reached on 116/139 statements (83%). Themes were identified and statements were categorized according to the domains of the ICF-CY. Consensus was reached on the importance of the clinical presentation of the child, consisting of physical and cognitive conditions, when determining content and focus of physical rehabilitation. In addition, consensus was reached on the importance of participation-focused interventions. Involvement and engagement of parents and siblings was seen as very important, both in goal setting and in therapeutic activities to stimulate transfers of skills and to increase dosage of practice. Although dosage of practice was scored as very important, no consensus was reached about the determination of dose-response variables to suit the individual needs of the child and adolescent with ABI.
Interpretation: This study highlights the importance of tailored physical interventions, aligned with the child and adolescent’s individual and developmental needs. Although it might be difficult during subacute rehabilitation to experience daily life activities as in the own home environment, interventions should be aligned with future participation in mind. Involvement and engagement of family members are essential and their contribution to the delivery of interventions to achieve adequate dosing of physical activity during subacute rehabilitation should be explored.
280 Sense of coherence (SOC) from 10 to 16 years after a traumatic brain injury
Jan Lexella, Lars Jacobssona
aLund University, Lund, Sweden
ABSTRACT
Background: Traumatic brain injury (TBI) is a leading cause of long-term disability. One factor of importance for a person’s ability to adapt and retain a positive view on life is Sense of Coherence (SOC), consisting of comprehensibility, manageability, and meaningfulness. Very little is known about SOC many years after a TBI and changes over time.
Objectives: The objectives were to describe SOC and changes over a six-year period among adults with long- term TBI, and to investigate how changes in SOC are associated with different socio-demographics and injury characteristics.
Material and Methods: Data from 45 participants (39 men and 6 women, median age 49 years) were included in the study. The participants had sustained a mild TBI (n = 20) or a moderate/severe TBI (n = 25). Data were collected on average 10 years and 16 years after TBI. The SOC-13 scale was used to rate the participants SOC. Descriptive statistics and Wilcoxon signed rank test were used for statistical analysis.
Results: There was no statistical difference in SOC between the two follow-ups (65 at first follow-up, 64 at second follow-up). Participants below median age (49 years) had a significant reduction in SOC (63 at first follow-up, 59 at second follow-up). There was no significant change in SOC among participants regarding sex, age at injury, time after injury, and injury severity.
Conclusions: Adults aging with long-term TBI have a SOC similar to the non-disabled population, indicating that they generally have a strong ability to handle stressful events in life. SOC was stable over time, regardless of sex, age at injury, time after injury, and injury severity, but younger participants had a decline in SOC over time. More studies are needed to better understand factors that affect the well-being of people living with a remaining disability from TBI, and how follow-up programs can be further optimized.
281 A road map of a PhD program of research: a step-by-step approach toward evidence-based subacute physical rehabilitation in children and adolescents with acquired brain injury
Christiaan Gmelig Meylinga,b,c, Olaf Verschurena, Ingrid Rentinckb, Raoul Engelbertf,g,h, Jan Willem Gortera,d,e
aCenter of Excellence for Rehabilitation Medicine, Utrecht, The Netherlands, Utrecht, Netherlands, bDepartment of Pediatric Rehabilitation, De Hoogstraat Rehabilitation, Utrecht, The Netherlands, cHU University of Applied Sciences Utrecht, Institute of Human Movement Studies, Master Pediatric Physiotherapy, Utrecht, The Netherlands, dDepartment of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands, eDepartment of Pediatrics, CanChild Center for Childhood Disability Research, McMaster University, Hamilton, Canada, fDepartment of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands, gFaculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands, hDepartment of Pediatrics, Amsterdam UMC, Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
ABSTRACT
Background: Physical activity has positive effects on physical, cognitive and social-emotional functioning in daily life, but also on specific brain structures and functions. This illustrates the potential of physical activity as a recovery mechanism for children and adolescents with acquired brain injury (ABI) during subacute rehabilitation. However, it is unclear how these new insights should be translated to clinical practice. The aim of our research program is to gather and create knowledge in order to develop an evidence-based physical rehabilitation program focusing on optimal recovery, functioning and participation in children and adolescents with ABI in the subacute phase.
Methods: This PhD-research project contains a step-by-step approach involving close collaboration between researchers, professionals, children and adolescents with ABI and their parents. Each step builds on previous acquired knowledge and experience. During the first phase, we built a foundation for future intervention studies, including I) a literature study, II) an international expert consensus study, and III) a qualitative study in children and adolescents with ABI and their parents. The results will inform the second phase: the development of an evidence-based physical rehabilitation program, which will be done with all relevant stakeholders. The third phase includes a pilot study to investigate the feasibility and acceptance of the intervention program in clinical practice with children and adolescents with ABI.
Results: The scoping review revealed that the current body of evidence about the characteristics and effects of physical rehabilitation interventions in children and adolescents with ABI during subacute phase is limited. The Delphi study resulted in a consensus-based framework with general principles of neuroplasticity, motor learning and family-centered care. However, no consensus was reached about the determination of dose-response variables to suit the individual needs of the child and adolescent with ABI. In the qualitative study, perspectives from children, adolescents and parents expressed the need for a more intensive physical rehabilitation program, sufficiently tailored to the individual needs of the patient. The second phase is ongoing. Increased dosage of physical practice in meaningful activities (participation-focused) and involvement of parents and siblings are essential ingredients for the program to be developed. Consideration is given to the organization and implementation in clinical practice.
Interpretation: Physical interventions during subacute rehabilitation have potential to improve functional recovery in children and adolescents with ABI, with intervention characteristics (frequency, intensity, time and type) as an important factor influencing its effectiveness. The results of the review, the Delphi study and the qualitative study offer a consensus-based framework for the current development of a tailored and effective physical rehabilitation program for children and adolescents with ABI during the subacute phase. In this PhD-research project we take up the challenge to optimize physical rehabilitation practice for children and adolescents with ABI and their parents.
282 The effect of esmolol on pressure reactivity index (PRx) in adults with severe traumatic brain injury
Thomas Baumera, Kati Hayesa, Matt Thomasa
aSouthmead Hospital, Bristol, United Kingdom
ABSTRACT
Introduction: Beta-blockade after severe traumatic brain injury (TBI) may improve functional outcome and survival. The mechanism underlying this effect is uncertain. Impairments of cerebral autoregulation are associated with worse outcome after TBI and in pigs may be mitigated by beta-blockade. It is not known if this is true in humans. Here we report findings from a single center phase 2a study of early beta-blockade with esmolol in adults with severe TBI (EBB-TBI; ISRCTN 11038397) regarding the effect of esmolol on pressure reactivity index (PRx), an accepted marker of cerebral autoregulation.
Method: We identified a subset of participants in the EBB-TBI study who also had continuous cerebral autoregulation monitoring with ICM+ (Cambridge Enterprise). Esmolol starting within 24 hours of injury was titrated to a heart rate of > 15% below baseline (defined as mean heart rate in the 4 hours prior to enrollment) according to study protocol. All other care followed unit policies based on Brain Trauma Foundation guidelines and directed by the treating intensivist. The initial 12-hour period (starting at 4 hours post-infusion to allow time for calculation of PRx) is presented in consecutive three hour epochs.
Results: Data from five from a total of 12 participants was analyzed. Baseline characteristics were (mean, SD): age 41.4 (19.7) years; APACHE-II score 11.2 (5.1); pre-intubation GCS 6.0 (2.3); injury-to-esmolol-time 18.1 (8.6) hours; Helsinki score 4.4 (4.0); ICU days 16.2 (8.5). The mean IMPACT predicted 6-month mortality was 24.2% and actual mortality 20%. Over 12 hours, mean (SD) esmolol dose in micrograms/kilogram/minute was 38.1 (9.5) and mean PRx 0.10 (0.14). In three hour epochs, mean esmolol doses (SD) were 24.6 (1.9), 35.6 (3.4), 44.4 (1.7), 48.1 (2.8). Mean PRX values were 0.14 (0.13), 0.12 (0.15), 0.13 (0.12) and −0.01 (0.13) respectively. Pearson’s correlation coefficient was −0.30.
Discussion: This is the first report of the effect of beta-blockade with esmolol on PRx in adults after severe traumatic brain injury. High PRx values reflect impaired autoregulation and can be prognostic, with an upper threshold of 0.05 for favorable outcome and 0.25 for survival. We did not observe any detrimental effect of esmolol on cerebral autoregulation, and with increasing duration and dose of esmolol saw a fall in PRx to a value consistent with favorable outcome. This could represent protection of autoregulation by esmolol in humans, but in the absence of a control group this remains a hypothesis. The limitations of a small single-center study and risk of bias with unsystematic patient selection must also be acknowledged.
Conclusion Beta-blockade does not adversely affect cerebral autoregulation early after severe TBI in adults. Mitigation of TBI-driven autoregulation impairment could account for some of the benefit of beta-blockade. Further research is needed.
283 Cognitive communication disorders after acquired brain injury: a systematic review of currently available measurement instruments using the COSMIN standards
Carmen Verhoeksa, Boudewijn Busa, Indira Tendolkarb, Sophie Rijnena
aHuize Padua Clinical Center for Brain Injury and Psychiatry, GGZ Oost Brabant, Boekel, Netherlands, bRadboud University Medical Center, Department of Psychiatry, Nijmegen, Netherlands
ABSTRACT
Introduction: Cognitive communication disorders (CCDs) are common after acquired brain injury (ABI). Identification of these disorders early during the rehabilitation process is important to enable intervention and improve functional outcome. Unfortunately, there is a lack of consensus on standardized measurement instruments for the assessment of CCDs in patients with ABI.
Objective: The aim of this systematic review is to identify, describe and critically appraise the currently available measurement instruments for the assessment of CCDs in adults with ABI. Furthermore, we strive to formulate recommendations on the use of the currently available measurement instruments based on feasibility, interpretability and psychometric aspects.
Methods: We conducted a systematic literature search in PubMed, EMbase, Cinahl, PsycInfo, ProQuest and Web of Science on January 3rd, 2022. We included studies on the development, psychometric evaluation and cross-cultural validation of measurement instruments for the assessment of CCDs in adults with ABI. We extracted data on study characteristics, psychometric properties and feasibility as well as interpretability aspects of the identified measurement instruments. Two reviewers (CV and SR) independently evaluated the methodological quality of the studies, rated the psychometric properties of the measurement instruments and graded the level of evidence using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN).
Results: Eventually, 62 articles were included reporting on 39 measurement instruments. We identified seven categories of measurement instruments: patient-reported (n = 5), proxy-reported (n = 2), performance-based (n = 11), clinician-rated (n = 10), interview-based (n = 2) and multiple-methods measurement instruments (n = 7), as well as item pools (n = 2). We are currently compiling an overview of (a selection of) the identified measurement instruments that will be presented at the conference, as well as psychometric properties and feasibility and interpretability aspects.
Conclusion: The number of measurement instruments with high-level evidence for at least one sufficient psychometric property is limited. Most identified measurement instruments have potential to be recommended for use, but require further psychometric research to assess their quality.
Clinical Implications: This review is intended to serve as an evaluative resource to guide clinicians and researchers in their decision-making process in this area. Furthermore, we intend to raise awareness of CCDs after ABI and to facilitate diagnostics and research in this field.
Prospero registration number: CRD42020196861
284 Current knowledge and attitudes of concussion injury prevention strategies in Irish rugby
Richelle M. Williamsa, Caithriona Yeomansb, Fiona Wilsonc
aDrake University, Des Moines, USA, bIrish Rugby Football Union, Ballsbridget, Ireland, cTrinity College Dublin, Dublin, Ireland
ABSTRACT
The prevalence of concussions in sports is a significant public health burden, with the incidence of concussions increasing annually among athletic populations. The most supported strategy to help prevent a concussion is through policy and increased knowledge of stakeholders, yet prevention strategies vary widely, and effectiveness is unclear. Thus, coaches and officials are likely key stakeholders in making policy changes and implementing new prevention strategies in sports. Therefore, we aimed to assess rugby stakeholders’ current knowledge and attitudes surrounding concussion injury prevention strategies.
Research Design: A three-research team conducted interviews using consensual qualitative research methods (CQR).
Methods: In this qualitative research study, 8 participants (males = 6, females = 2; referees = 6, coaches = 2; age = 49 ± 10.95 years, number of years in sport = 12 ± 10.06) were interviewed. Participants were recruited through purposeful sampling with an e-mail sent through rugby associations. Participants were interviewed over Zoom using a semi-structured interview guide (eight demographic questions and 21 prevention questions). All interviews lasted between 30 minutes and 1 hour and were recorded, transcribed verbatim, and checked for accuracy. Data analysis included thematic content analysis using three researchers to create themes. The researchers each reviewed the transcripts separately to outline themes. Data interpretation included coding the initial themes separately and creating a consensus to determine the final themes.
Results: When interviewing participants on concussion prevention strategies, we identified five primary themes: 1. recognition of concussion education and awareness of signs and symptoms, 2. the role of the referee as an advocate for recognize and remove, 3. the importance of stakeholder involvement, 4. recognition of the coach’s role in prevention, and 5. importance of training and advocacy from the professional body.
Discussion: Referees highlighted that their concussion education training and awareness of signs and symptoms following injury was part of their initial training and not updated annually. Further, participants highlighted and focused on their role as referees to advocate for athlete participation and implement the recognize and remove platform during match play. This role focuses on injury prevention through recognizing potential risk events and understanding secondary concussion prevention strategies. In contrast, coaches identified their role in preventing concussions by improving tackling techniques to create a safe environment for players. It is essential to incorporate all stakeholders throughout concussion injury prevention strategies, including education, creating awareness, implementing a safe sport environment, and reducing concussion risk in rugby. Part of this comes from a top-down approach, including the governing body organization and highlighting the importance of training and advocacy. Coaches and referees are key stakeholders in supporting policy change, enforcing rules, and communicating with parents and athletes. Incorporating their perspectives and understanding of injury prevention strategies helps guide the development of appropriate strategies with the end-user in mind.
285 Effects of photobiomodulation treatment on cognitive function and underlying resting state functional connectivity in adults with a history of repetitive head impacts: a feasibility study
Dr. Carrie Esopenkoa,b, Hannah Lindseyb,c, Paula Johnsonb,c,d, Mary Newsomeb,e,f, Spencer Liebelb,c, Finian Keleherb, Tanner Guderianb, Elizabeth Hovendenb,c, Michael Larsond, Hilary Russellb,c, Dayna Thaynb,d, Carmen Velezb,c, Christine Mullenb, Emma Readb, Lance Davidsonb,d, Lawrence Carrb, Elisabeth Wildeb,c,f
aICAHN School of Medicine at Mount Sinai, New York, USA, bUniversity of Utah, Salt Lake City, USA, cGeorge E. Wahlen VA Medical Center, Salt Lake City, USA, dBrigham Young University, Provo, USA, eMichael E. DeBakey VA Medical Center, Houston, USA, fBaylor College of Medicine, Houston, USA
ABSTRACT
Repetitive head impacts (RHI), blows to the head not resulting in observable clinical symptoms or concussion, may result in chronic impairments in memory, attention, and executive function, which may negatively impact one’s mental health and overall quality of life. Recently, photobiomodulation (PBM), a form of light therapy delivered to the brain via an LED headset, has been proposed as a noninvasive, low risk, relatively inexpensive, and easy-to-use treatment. The purported mechanisms that enhance circulation, improve mitochondrial function and energy production, and reduce inflammation address the cognitive sequelae experienced following traumatic brain injury. In the present proof-of-concept study, we investigated whether PBM may have similar implications for individuals exposed to RHI, in that it may reduce the risk of long-term, negative cognitive impairments and improve the underlying functional connectivity of the brain. Thirty patients (28 male) between the ages of 22–69 (M = 46.3 ± 15.2) with a self-reported history of RHI exposure [between 4–30 (M = 13.3 ± 6.7) years] were included in the present study. Exclusion criteria included a history of neurologic disease or psychiatric disorder and MRI contraindications. An at-home PBM headset was used for 20 minutes, 3–5 times per week over the course of 8–10 weeks. The device delivers 25 milliwatts of near-infrared (NIR) light to the frontal and frontoparietal lobes. Additionally, an intranasal probe was used simultaneously to deliver a single wavelength of NIR to subcortical structures and the orbitofrontal cortex. Combined, these lights deliver a total of 240 J/cm2 pulsed at 40 Hz. Cognitive function was assessed using standard neuropsychological measures of memory, attention, and executive functioning, while seed-based resting-state functional connectivity (rsFC) was assessed using resting-state functional MRI (rsfMRI) before and after the PBM intervention. Within-group comparisons of change in cognitive function and rsFC over time were performed. Pre-to-post PBM intervention change scores for each cognitive measure, as well as rsFC parameter estimates for default mode (DMN), salience (SN), and central executive (CEN) network seeds were calculated. Exploratory correlational analysis was then used to investigate the relationship between changes in cognitive function and changes in rsFC following the intervention. Our results demonstrated a post-intervention increase in all measures of cognitive function, as well as meaningful changes in rsFC across networks. Our results further suggest that the improvements in memory are largely associated with changes in the CEN, and to a lesser extent, the DMN, whereas improvements in attention show greater associations with changes in the SN following the PBM intervention. These findings have promising implications for the use of PBM in treating potential chronic sequelae of RHI in adults, namely through alterations in the underlying physiology.
286 Speech-language pathology rehabilitative services following concussion: an exploratory study of person-centered goals
Katy O’Briena,b, Yalian Peia, Amy Kempa, Rebecca Gartellc, Russell Gorec, Tracey Wallacec
aUniversity of Georgia, Athens, USA, bCourage Kenny Rehabilitation Institute, Minneapolis, USA, cShepherd Center, Atlanta, USA
ABSTRACT
Rehabilitation and early intervention following concussion are increasingly recognized as best practice to facilitate uncomplicated recovery or quickly fast track care for those at risk for complicated recovery. Speech-language pathology services are often recommended for those with cognitive or fatigue phenotypes following concussion. Person-centered goals identified through problem-focused interviewing can complement traditional clinician-directed rehabilitation goals and help rehabilitation professionals shape treatment plans to meet individual needs. While more common in serving individuals with moderate to severe brain injury, they are less frequently implemented in concussion care. In this exploratory retrospective chart review study, person-centered goals were extracted from medical records of patients who received speech-language pathology services for concussion at a specialty clinic between August 2019 and March 2020. Goals were coded according to the World Health Organization International Classification of Functioning, Disability, and Health model (WHO-ICF; (i.e., impairment, activity, participation), contextual environmental setting (home, work, school, community), domain (cognitive, communication, emotional, or other), as well as by alignment with items in the Post-Concussion Symptom Scale (PCSS). Three reviewers independently coded goals, with discrepancies in ratings resolved through consensus. Fifty-nine charts met inclusion criteria. Mean patient age was 31.85 (17.31), 19 were male, and mean time post injury was 129 days. Most goals were at the activity level (46%), followed by participation (32%), and impairment (22%). Return to productivity was central to patient goals, with almost half addressing return to school (49%) and 21% specifying return to work. Community made up just 6% of goals, and home 1%. An additional 23% did not specify a setting. Goals were primarily cognitive in nature (62%), followed by communication (13%), emotional regulation (13%), or other unspecified domains (12%). Almost all goals were restorative (86%), suggesting most patients expected full resolution of symptoms and return to prior function. Just 14% of goals reflected compensatory approaches, including development of strategies and management techniques. Most goals were not represented on the PCSS; as expected, those that were reflected cognitive needs, including difficulty concentrating (17%), difficulty remembering (13%), feeling mentally foggy (3%) and just a single goal addressed resolution of headache. Of the remaining 63% of goals not represented, most were related to managing effort, efficiently completing tasks, reducing feelings of being overwhelmed, or more general statements of successfully returning to school and work. A few addressed particular modalities such as writing or public speaking. Patients experiencing symptoms of concussion referred for speech-language pathology services may commonly seek improvement in disability and functioning related to activity and participation at school and work. Person-centered goals are not well captured by standard symptom scales, thus emphasizing a need for rehabilitation providers to use problem-focused interviewing or other person-centered methods to identify personally relevant and meaningful goals in this population.
287 The relationship between objectively measured physical activity and cognitive functioning during the first year after moderate to severe traumatic brain injury
Charles Bombardiera, Dmitry Esterovb, Sujata Pradhana, Simon Driverc, Kathleen Belld, John Whytee, Jason Barbera, Nancy Temkina
aRehabilitation Medicine, University Of Washington, Seattle, USA, bMayo Clinic, Rochester, USA, cBaylor Scott and White Research Institute, Frisco, USA, dUniversity of Texas, Southwestern, Dallas, USA, eMoss Rehabilitation Research Institute, Philadelphia, USA
ABSTRACT
Introduction: Traumatic brain injury (TBI) has been conceptualized as a chronic health condition in which lifestyle behaviors may influence outcomes.1 Physical activity (PA) has been highlighted as an example of a healthy behavior that might positively influence recovery.1 In the general population, there is moderate to strong support for the hypothesis that engaging in at least 150 minutes per week of moderate to vigorous PA (MVPA) benefits cognitive functioning.2 However, we lack data on the relationship between MVPA and cognition after TBI. Therefore, we conducted a longitudinal cohort study to ascertain the cross-sectional and predominant temporal relationships between MVPA and cognition during the first year after TBI.
Methods: Adult ambulatory patients at four TBI Model Systems inpatient rehabilitation centers in the U.S were recruited before discharge. Those who consented wore a triaxial accelerometer, the Actigraph GT3X, on their nondominant wrist continuously for 7 days after discharge from IPR and at 6 and 12 months post-TBI. Accelerometer data were scored in 60 second epochs using a cut score of at least 2020 counts per minute to define MVPA. Participants also completed the Brief Test of Adult Cognition by Telephone (BTACT) around the same time points and the composite score was used to capture cognitive functioning. We used cross-lagged panel correlations to determine whether MVPA and cognition were related cross-sectionally and longitudinally. Multiple imputation was used to account for missing outcomes.
Results: 180 participants were recruited. The sample was 81% male, 49.9 years old on average, and 39% followed commands within one day of TBI. We obtained valid accelerometer data on 140, 105, and 93 participants at baseline, 6 months, and 12 months, respectively. The correlations between minutes of MVPA at different time points were significant (r = 0.44–0.73) as were correlations between BTACT composite scores at different time points (r = 0.52–0.71). However, no significant correlations were observed between minutes of MVPA and BTACT composite scores cross-sectionally or longitudinally at any time point.
Discussion: Contrary to expectations we observed no relationship between objectively measured MVPA and cognitive functioning in this sample. Limitations include the potential insensitivity of the BTACT to MVPA effects, difficulties with participant retention during the COVID pandemic, and the fact the sample was skewed toward more active persons. Future post-hoc subgroup analyses are warranted to determine whether there may be a relationship between these constructs for some aspects of cognition (e.g., executive functioning) and within some participant subgroups (e.g., women).
288 The SUCCESS peer mentoring program for students with concussion: a pilot study of academic and psychosocial outcomes
Dr. Katy O’Briena,b, Yalian Peia, Amy Kempa, Rebecca Gartellc, Tracey Wallacec
aUniversity of Georgia, Athens, USA, bCourage Kenny Rehabilitation Institute, Minneapolis, USA, cShepherd Center, Atlanta, USA
ABSTRACT
Concussions are a common injury in college students. Physical, cognitive, sleep, and emotional symptoms may interfere with academic participation, limiting students’ ability to be in the classroom or keep up with lectures, learning, and assignments. For those who sustain an injury outside of varsity sports, students must seek care independently, both for medical treatment and management of academic complaints. Peer mentoring may be a particularly well-suited approach for college students with concussion, as it taps into key elements known to benefit students with more chronic disabilities in postsecondary settings, including supporting both independence and belonging. Previous studies of peer-led education show that people with disabilities learn and retain more when information is delivered by peers rather than medical professionals, and mentoring provides psychosocial benefits to both mentor and mentee alike. The Success in College after Concussion with Effective Student Supports (SUCCESS) peer mentoring program matches newly injured students with students who have sustained a concussion during their postsecondary studies and successfully returned to learn. In this pilot study, nine mentees and seven mentors completed measures pre and post a four-week intervention period. Peer mentoring was delivered virtually through a mobile application and supported by educational materials developed by students with concussion and other stakeholders (e.g., rehabilitation professionals, disability resource coordinators). Primary outcomes were the Post-Concussion Symptom Survey; Academic Dysfunction Survey; College Academic Self-Efficacy Scale; PROMIS Self-Efficacy Scale; and Depression, Anxiety, and Stress Scale. Wilcoxon signed rank tests were used to assess the impact of mentoring on mentors and mentees. Results showed that mentee symptoms (V = 45, p = 0.004) and academic complaints (V = 41.5, p = 0.028) decreased from pre to post indicating resolution of symptoms and improvement in ability to perform academic tasks. Additionally, academic self-efficacy increased (V = 3.5, p = 0.028), with mentees demonstrating increased confidence in their ability to manage academic demands. There were no changes in general self-efficacy (V = 7, p = 0.529) or quality of life measures (V = 12, p = 0.25), although there was a trend toward a decrease in negative emotions (V = 31, p = 0.079). Mentor measures were stable from pre to post, with no changes in concussion symptoms, although trends toward improvement in mental health (V = 24.5, p = 0.090), and 5 of 7 mentors experiencing gains in general self-efficacy (V = 5, p = 0.149) suggest these constructs may be important to examine in future expanded trials. Results of this pilot study examining a virtual peer mentoring intervention for students with concussion indicate this approach is well tolerated by both acutely injured mentees as well as mentors. Improvements in mentee self-efficacy and symptomatology along with trends toward other mentee and mentor gains suggest peer mentoring may have positive effects on psychosocial function following concussion. Future research examining the impact of SUCCESS on mentors and mentees in a fully-powered randomized controlled trial is warranted.
289 A feasibility study for the use of photobiomodulation to improve psychological health through alterations in resting state functional connectivity in adults with a history of repetitive head impacts
Hannah Lindseya,b, Carrie Esopenkoa,c, Paula Johnsona,b,d, Mary Newsomea,e,f, Spencer Liebela,b, Finian Kelehera, Tanner Guderiana, Hilary Russella,b, Carmen Veleza,b, Dayna Thayna,d, Christine Mullena, Elizabeth Hovendena,b, Emma Reada, Lance Davidsona,d, Michael Larsond, Lawrence Carra, Elisabeth Wildea,b,f, David Tatea,b
aUniversity Of Utah, Salt Lake City, USA, bGeorge E. Wahlen VA Medical Center, Salt Lake City, USA, cICAHN School of Medicine at Mount Sinai, New York, USA, dBrigham Young University, Provo, USA, eMichael E. DeBakey VA Medical Center, Houston, USA, fBaylor College of Medicine, Houston, USA
ABSTRACT
Long-term changes in mood, sleep quality, and adaptive functioning may result from repetitive head impacts (RHI), or blows to the head that do not result in observable clinical symptoms or concussion, impairing neurocognitive and psychiatric health. Recently, a form of light therapy that is noninvasive, low risk, relatively inexpensive, and easy-to-use, called photobiomodulation (PBM), has been proposed as a treatment for the psychological sequelae experienced following traumatic brain injury. The proposed cellular mechanisms of PBM result in enhanced circulation, improved mitochondrial function and energy production, and reduced inflammation. In the present proof-of-concept study, we investigated whether PBM may have similar implications for individuals exposed to RHI, in that it may reduce the risk of long-term, negative psychological sequelae and improve the underlying resting-state functional connectivity (rsFC) of the brain. The present study included 30 adult patients (28 male) with a self-reported history of RHI exposure [between 4–30 (M = 13.3 ± 6.7) years] and ages ranging between 22–69 (M = 46.3 ± 15.2) years. Exclusion criteria included a history of neurologic disease or psychiatric disorder and MRI contraindications. An at-home PBM headset that delivers 25 milliwatts of near-infrared (NIR) light to the frontal and frontoparietal lobes was used for 20 minutes, 3–5 times per week over the course of 8–10 weeks. Additionally, an intranasal probe was used simultaneously to deliver a single wavelength of NIR to the orbitofrontal cortex and subcortical structures. Combined, the PBM device delivers a total of 240 J/cm2, pulsed at 40 Hz. Before and after the PBM intervention, psychological function was assessed using self-report measures of posttraumatic stress disorder (PTSD), depression, sleep quality, and adaptability, while seed-based rsFC was assessed using resting-state functional MRI (rsfMRI). Within-group differences in change in psychological function and rsFC was assessed over time. Pre-to-post PBM intervention change scores for each psychological measure and for rsFC parameter estimates extracted from default mode (DMN) and salience network (SN) seeds were calculated. Correlational analysis was then used to explore the relationships between intervention-related changes in psychological function and intervention-related changes in rsFC. Post-intervention improvements were observed across all measures of psychological function, and meaningful changes in rsFC were observed across the two networks. The results of the correlational analysis further suggest that changes in both the DMN and SN are associated with improvements in symptoms related to PTSD, sleep, and social function, and changes in the SN are also associated with improvements in depression symptoms following the PBM intervention. These findings have promising implications for the use of PBM in improving psychological health through alterations in rsFC in adults with a history of RHI.
290 Early intervention for persistent post-commotional symptoms after mild traumatic brain injury: a Parisian experience
Clémence Lefevre-Dognina, Valérie Perdrieaua, Aurélie Grangera, Emmanuelle Normanda, Jade Griblotb, Maryame Gatineaub, Mélanie Cognec, Philippe Decqb, Philippe Azouvia
aNeurorehabilitation unit, Raymond Poincaré Hospital, Garches, France, bNeurosurgery unit, Beaujon Hospital, Clichy, France, cNeurorehabilitation unit, CHU Pontchaillou, Rennes, France
ABSTRACT
Objectives: The objective of this program is to provide early detection and early management of Individuals with persistent post-concussion symptoms (PCS) after mild traumatic brain injury (mTBI).
Methods: Then program is organized in a two-stage process: the first step is the detection of all ER patients with a diagnosis of mTBI. A Remote follow-up (telephone, e-mail) by a coordinating nurse followed, if necessary, by a medical consultation by a specialist in the same hospital. In case of PCS persistent beyond 4 weeks, multidisciplinary management in day-hospital in a rehabilitation unit (psycho-education, reassurance, psychological support, cognitive rehabilitation) is organized over 6 weeks.
Results. During 4 years, 2,278 patients were seen in the Beaujon and Bichat Hospitals ER for a mTBI, of which 2,107 (92%) were contacted within a month, 748 of which did not report any difficulties or refused to participate. 1103 patients (52%) received a telephone interview, of which 155 were seen in a neurosurgical consultation. 131 patients (6% patients contacted by the nurse) were evaluated and included in the multidisciplinary program. Preliminary analyses of a sub-group of 59 patients who had completed the entire program showed a significant improvement in several measures (cognition, PCS, post-traumatic stress, mood). Older age was one of the only predictors of poorer improvement.
Discussion: Although this is a non-randomized observational study without a control group, these preliminary results demonstrate the feasibility of an early detection program to reduce the risk of persistent PCS, with seemingly encouraging results.
291 Who is at risk? Exploring and describing clinical features of children requiring psychiatric care following a mild traumatic brain injury
Mari Saarinena,b, Leena Himanena,b, Olli Tenovuoa,b, Tuire Lähdesmäkia,b
aUniversity of Turku, Turku, Finland, bTurku University Hospital, Turku, Finland
ABSTRACT
Even a single mild traumatic brain injury (mTBI) during childhood has been shown to increase the risk for psychopathology development and need for psychiatric care later in life. A novel psychiatric disorder has been reported to emerge in 10 to 30% of the cases following hospital-treated pediatric mTBI. Several pre- and post-injury factors related to development of later psychiatric problems have been recognized, with pre-injury psychiatric disorders and female sex being the strongest predictors.
In our retrospective patient register study including 120 Finnish school-aged children treated at the Turku University Hospital due to an mTBI, we found that 29 (24%) children had had a contact in psychiatric services during the follow-up period of 7 years. Of these, 18 (15% from the cohort) had their first psychiatric contact after sustaining an mTBI without having preinjury psychiatric contact.
In this work we will describe and discuss in detail injury- and non-injury-related features as well as the nature of post injury psychiatric problems in children having their first psychiatric contact following an mTBI.
292 Introducing a pilot visual perception assessment tool for occupational therapists working with children within the acute setting following a traumatic brain injury
Sinead Leahya
aChi At Temple Street, Dublin, Ireland
ABSTRACT
Background: Studies show that 90% of traumatic brain injuries (TBI) result in visual dysfunction which present in many ways e.g. oculomotor control, visual acuity, visual field changes. These are the basic visual skills that make up the foundations for vision. Higher up the visual hierarchy is visual perception, which describes how the brain interprets, understands and defines incoming visual information. Difficulties in this area can be more subtle and have a significant impact on a child’s ability to function and on their overall occupational performance. As Children’s Health Ireland at Temple Street is the neurosurgical center for children in Ireland, with a lead consultant for neuro rehabilitation, it is important that we assess and support children’s recovery in this area.
The Occupational Therapy (OT) team were referred 25 children in the last 6 months with a TBI. The focus for these patients is often motor function, fatigue management and functional skills, with visual perception being assessed on an impromptu basis, often once these other areas are addressed. Where there has been no organic visual damage, it is important to explain the nature of visual perception difficulties to families and patients. If a child is not accurately processing visual information from their environment it is both frightening and a greater challenge to participate in motor, cognitive and functional goals.
Method: Retrospective chart reviews were completed to review current timeframes and assessments used with patients following a traumatic brain injury.
A literature search was completed and we linked in with other occupational therapy teams to review best practice in this area.
Results: Chart reviews found that of the 25 children referred in the last 6 months:
23% visual skills were assessed and described
64% visual perception was assessed and described (there was no uniformity in how visual perception was assessed in 54% of files. Only 10% of overall reviewed used similar assessment method)
12% had no evidence of visual or perceptual assessment.
A visual perceptual tool has been drafted and is being piloted.
Conclusion: This poster shows the background and pilot for a visual perceptual assessment tool for children admitted to CHI at Temple Street following a TBI. This tool supports OT’s in assessing visual perception consistently, highlighting it as a key area early on in a child’s care. It will help identify if a standardized assessment is required in a particular area. It also supports OT’s in explaining how difficulties might present functionally. It provides the multi-disciplinary team with key information about a child’s visual processing skills which are likely to have a significant impact on their other areas of rehabilitation and can sometimes be mistaken for cognitive, motor or visual difficulties.
293 Establishing an acute rehabilitation service in a tertiary pediatric hospital: a quality improvement project
Jillian Pouncha, Mr Irwin Gilla,b,c, Sinead Leahya
aCHI At Temple Street, Dublin, Ireland, bThe National Rehabilitation University Hospital, Dun laoghaire, Ireland, cSchool of Medicine, University College Dublin, Belfield, Ireland
ABSTRACT
Background: In 2020, Children’s Health Ireland at Temple Street became the single national pediatric neurosurgical center for Ireland. In response to an increased caseload and an influx of new staff, Quality Improvement (QI) methodology was used to reduce unwanted variation in acute rehabilitation care.
Methods: The neurosurgical database was analyzed over a 6-month period to identify patients eligible for rehabilitation; this was cross-referenced with the rehabilitation database to identify timings of referrals and reviews, as well as missed referrals.
Children and families were surveyed (based on the Children’s Healthcare Charter and MPOC-20) to assess satisfaction with processes of care. Team members were surveyed to assess perceived barriers to interdisciplinary care and engaged in a shared process mapping initiative. QI methods were used to implement changes and measure improvement.
Results: Surveys of children and families revealed positive feedback. Parents outlined distress in the initial phase of admission at having to “retell their story” to multiple professionals, who seldom conducted joint interdisciplinary reviews. Families also reported a desire for more written information.
Joint process mapping identified discrepancies between “work as imagined” and “work as performed” with opportunities for improved consistency identified.
Late referrals were the main cause of delayed initial rehabilitation review. A median of 3 eligible patients per month were not referred for rehabilitation review at all.
In response this data, the Rehabilitation Clinical Nurse Specialist joined the neurosurgical team on one ward round per week; missed referrals dropped to 2 in February 2022 and 1 in March 2022. Residual missed referrals were typically for patients admitted over weekends; the introduction of a referral documentation system for these patients reduced missed referrals to zero.
Surveys of team members identified that three key issues accounted for over 80% of perceived barriers to joint working: lack of understanding of the roles of other therapists, a lack of joint sessions and significant staff turnover.
An exercise completed with team members highlighted areas of shared professional responsibility and overlap. Review of medical records confirmed no initial assessments were carried out jointly during the study period. 66% of families reported repeating information at the initial stages of admission. It also identified significant redundancy in therapy input. For example, 50% of records reviewed showed home environment was discussed by two or more therapists of different disciplines within the first 48 hours.
Conclusion: We describe the use of Quality Improvement methodology to reduce unwanted variation and embed interdisciplinary working within an acute rehabilitation service in a tertiary pediatric hospital. The methods and learning points raised are likely to be relevant to other centers. The development of information resources for families and methods to support joint initial assessments are targets for further improvement.
294 Accumulation of axonal injury and neurodegenerative changes associated with repetitive subconcussive head acceleration exposures in a biofidelic preclinical model
Rachel Cutlana, Jack Seiferta, Alok Shaha, Rachel Chiarielloa, Brian Stempera,b
aMedical College Of Wisconsin, Milwaukee, USA, bZablocki Veterans Affairs Medical Center, Milwaukee, USA
ABSTRACT
Subconcussive head impacts with magnitudes below the concussion threshold are sustained during routine participation in contact sports. Subconcussive head impact exposure (sHIE) can lead to decreased concussion tolerance/higher concussion risk. Identifying blood biomarkers that correlate with sHIE may help identify athletes at risk for concussion. Our laboratory developed a biofidelic preclinical model for sHIE with the number and severity of head acceleration exposures scaled to the rat from data collected in our studies of contact sport athletes. The goal of this experiment was to identify blood-based biomarkers for accumulating damage in the brain associated with sHIE. Sprague-Dawley rats were separated into four groups: high exposure (HE), moderate exposure (ME), single injury (SI), and sham. HE and ME received 30 and 8 low-magnitude head accelerations per day, five days per week for four weeks. SI received one high-magnitude head acceleration, sufficient to produce concussion, at the end of the four weeks. Blood was drawn for HE and ME groups at baseline and the end of each week to track progressive blood serum biomarker changes (neurofilament light, NFL; glial fibrillary acidic protein, GFAP; total tau, t-tau; neuron specific enolase, NSE). Blood was drawn from SI and sham rats at baseline and following single exposure/sham. All rats had blood drawn at the terminal timepoint, two weeks post injury. Biomarker levels at all timepoints were normalized to baseline. HE NFL levels were significantly elevated relative to baseline (p < 0.05) at all four timepoints during sHIE. The terminal measurement remained significantly elevated, but also significantly decreased from week 4 during the two-week absence of sHIE. ME rats had no significant elevation of NFL during the sHIE period, but the terminal measurement was insignificantly increased from baseline. SI rats saw a significant increase in NFL immediately following exposure. Sham rats saw a significant increase from baseline to terminal, which might partially explain elevated NFL levels at the terminal timepoint. HE, ME, and SI saw significantly higher NFL levels at peak sHIE compared to sham. T-tau and NSE levels also varied significantly between timepoints. HE and ME terminal t-tau levels were significantly increased from all previous blood draws. HE and SI terminal NSE levels were also significantly increased from all previous measurements. No significant changes in GFAP levels were found at any timepoint. This experiment showed a dose-dependent relationship between sHIE and certain blood biomarkers, which may be useful in tracking potential accumulating damage associated with sHIE. The HE group had significant axonal damage indicated by elevated NFL concentration, but not the ME group, showing that limiting excessive sHIE may be protective. The trend of t-tau and NSE peaking after sHIE ended may imply a chronic phenomenon, beyond the scope of this study, that deserves future attention.
295 Predicting suicidal ideation and attempts in veterans and service members over the 5 years after TBI: A U.S. veterans affairs model systems study
Paul Perrina,b, Bridget Xiab, Stefan Vasicb, Daniel W. Klyceb,c, Jessica M. Ketchumd, Tiffanie Vargasb,c, Thomas Campbellb, Jacob Finne,f, Lauren Fisherg,h, Ross Zafonteg,h, Shannon Juengsti, Kelli Garyc, Janet Niemeierj, Elizabeth Pasipanodyak, Laura Dreerj
aUniversity Of Virginia, Charlottesville, USA, bCentral Virginia Veterans Affairs Health Care System, Richmond, USA, cVirginia Commonwealth University, Richmond, USA, dCraig Hospital, Englewood, USA, eMinneapolis Veterans Affairs Health Care System, Minneapolis, USA, fUniversity of Minnesota, Minneapolis, USA, gMassachusetts General Hospital, Boston, USA, hHarvard Medical School, Boston, USA, iTIRR Memorial Hermann, Houston, USA, jUniversity of Alabama Birmingham, Birmingham, USA, kSanta Clara Valley Medical Center, San Jose, USA
ABSTRACT
Background: Veterans and Service Members (V/SMs) with traumatic brain injury (TBI) are 1.6–2.2 times more likely to die by suicide than those without TBI. This study examined demographic and injury-related predictors of suicidal ideation (SI) and attempts (SA) during the first 5 years after TBI among V/SMs enrolled in the U.S. Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC) TBI Model Systems Study.
Method: A sample of 812 V/SMs who had sustained their TBI between 2008–2017 completed the Patient Health Questionnaire-9 Item 9 (“Over the last 2 weeks, how often have you been bothered by any of the following problems? … Thoughts that you would be better off dead, or of hurting yourself”) and reported whether they had attempted suicide over the past year at Years 1, 2, and 5 after TBI. Participants had received inpatient rehabilitation at one of the VA’s five PRCs in Richmond, Minneapolis, Tampa, San Antonio, or Palo Alto; all participants enrolled in the current study within 14 months of injury and survived to at least the Year 1 data collection.
Results: Across the full sample, 4.8% of V/SMs with TBI reported a past-year SA at one or more of the three data collections during the first 5 years after injury, and 21.7% reported SI within 2 weeks of one of the data collections. Repeated-measures logistic regression models assessing each predictor alone suggested that V/SMs had higher SA probability trajectories if they had: been unmarried at injury (p = 0.044) and a history of pre-injury mental health treatment (p = 0.001). V/SMs had higher SI probability trajectories if they had: a violent cause of injury (p = 0.007), a history of pre-injury mental health treatment (p < 0.001), a history of pre-injury psychiatric hospitalization (p < 0.001), attempted suicide before injury (p < 0.001), not been on active duty at injury (p = 0.027), and not been deployed at injury (p = 0.045).
Discussion: Given the three discrete follow-up time points, reporting windows, and no data collection at follow up from individuals who died by suicide for the SI and SA outcomes, these rates – though extremely high – are likely underestimates of the actual 5-year post-TBI suicidality rates among V/SMs with TBI, even among those receiving comprehensive inpatient rehabilitation. V/SMs with TBI should be screened regularly for suicidality – even many years after injury – and the significant risk factors identified in this study can be used in future research to determine why they are associated with elevated SI/SA. These findings, along with further research on this topic, can help inform targeted screening and appropriate mental health referral for V/SMs with TBI in order to assess, monitor, and treat SI and SA.
296 Alterations in cognitive function and resting-state functional connectivity in cerebellar networks following photobiomodulation treatment in adults with a history of repetitive head impact
Finian Kelehera, Carrie Esopenkoa,b, Hannah Lindseya,c, Mary Newsomea,d,e, Paula Johnsona,c,f, Tanner Guderiana, Spencer Liebela,c, Elizabeth Hovendena,c, Hilary Russella,c, Christine Mullena, Carmen Veleza,c, Dayna Thayna,f, Emma Reada, Michael Larsonf, Lance Davidsona,f, Lawrence Carra, Elisabeth Wildea,c,e
aUniversity Of Utah, Salt Lake City, USA, bICAHN School of Medicine at Mount Sinai, New York, USA, cGeorge E. Wahlen VA Medical Center, Salt Lake City, USA, dMichael E. DeBakey VA Medical Center, Houston, USA, dBaylor College of Medicine, Houston, USA, fBrigham Young University, Provo, USA
ABSTRACT
While the cerebellum’s role in motor functioning is well understood, damage to the cerebellum may also result in alterations in cognitive functions including memory, attention, and executive function. The cerebellum has been shown to be vulnerable to traumatic brain injury and concussion, but less is known about the sequelae of repetitive head impacts (RHIs) to the resting-state functional connectivity (rsFC) of the cerebellar networks and potential approaches to treatment. The current study seeks to investigate the relation between cerebellar rsFC and cognitive function after RHI by utilizing a novel treatment called photobiomodulation (PBM). PBM is a noninvasive and accessible form of near-infrared light therapy that acts on biochemical processes to improve mitochondrial function, enhance circulation and tissue oxygenation, and reduce swelling. These effects suggest that PBM applied to the head may be beneficial to neurological function following brain injury. In the current study, 30 patients (28 male) with a self-reported history of RHI exposure [between 4–30 (M = 13.3 ± 6.7) years] and ages ranging between 22–69 years (M = 46.3 ± 15.2) used an at-home PBM headset 3 to 5 times per week over the course of 8–10 weeks. Individual PBM sessions included 20 minutes of light exposure to the frontal and frontoparietal lobes, as well as an intranasal probe that delivered a single beam of light to the orbitofrontal cortex and several subcortical structures. The PBM device delivered a total of 240 J/cm2 each session, pulsed at 40 Hz. Cognitive functioning was measured at baseline and after the completion of PBM treatment using standard clinical measures of verbal memory, attention and processing speed, executive function, and fluid cognitive ability. Similarly, rsFC was measured in anterior and posterior cerebellar seed regions before and after treatment using resting-state fMRI. Change scores were calculated for each cognitive task and each seed region, and an exploratory correlation analysis was performed to measure the association between pre-to-post intervention changes in rsFC and cognitive function. Performance improved on each of the cognitive tasks administered and several meaningful changes were observed in cerebellar network connectivity following the PBM intervention. The results of the correlational analysis suggest improvements in memory and attention are largely associated with changes in rsFC of anterior cerebellum regions, whereas improvements in executive function were associated with changes in rsFC of anterior and posterior regions of the cerebellum. These findings demonstrate the potential effectiveness of PBM as a treatment for alterations in cognitive functioning in individuals with history of RHI. Further, these results contribute to the growing body of research establishing the role of cerebellar networks in cognitive function and help elucidate the underlying mechanisms of cognitive sequelae following RHIs.
297 The association between anatomic and clinical indicators of injury severity after moderate-severe traumatic brain injury – a pilot study using multiparametric MRI
Dmitry Esterova, Ziyang Yina, Matthew Murphya, Trevor Persauda, Xiang Shana, Allen Browna, John Huston IIIa, Richard Ehmana
aMayo Clinic, Rochester, USA
ABSTRACT
Objective: Identifying predictors of post-acute outcomes after moderate-severe TBI is important for these individuals, their families, and care providers as they can inform customized plans of care to favorably influence them. While clinical indicators of injury severity [especially post traumatic amnesia (PTA)] have been shown to be predictive of outcome, an objective measure of anatomic injury severity that predicts clinical outcome is lacking. Magnetic Resonance Imaging (MRI) is far more sensitive in identifying altered brain anatomy after trauma, but its prognostic utility beyond the acute phase of injury after TBI remains uncertain. Furthermore, advanced MRI techniques such as MR Elastography (MRE) – an MR-based imaging modality that noninvasively and quantitatively maps the mechanical properties of tissues – has shown the potential for evaluating TBI in preclinical models, but its role in evaluating moderate-severe TBI is unknown. The primary objective of this study was to investigate the association between an anatomic indicator if injury severity as measured by multiparametric MRI/MRE and a clinical indicator of injury severity as measured by PTA during inpatient rehabilitation.
Methods: Nine individuals who were admitted to acute inpatient rehabilitation after moderate-to-severe TBI completed a comprehensive MRI protocol prior to discharge from rehabilitation. Non-hemorrhagic contusion scores were graded based on measuring the lesion sizes on FLAIR MRI sequences, and hemorrhage scores were based on counting the number of lesions on SWI MRI sequences. Of those, 5 of the 9 also underwent brain MRE exams to measure the brain parenchyma stiffness. The ratio of lesion stiffness to the contralateral normal brain tissue stiffness was calculated. The duration of PTA was assessed using serial administration of the modified Galveston Orientation & Amnesia Test recorded during acute inpatient rehabilitation. The Kruskal-Wallis test was used to compare imaging findings to the length of PTA. Statistical significance was set at p < 0.05.
Results: The hemorrhagic score was significantly higher in individuals with a longer length of PTA (P = 0.0262). Moreover, participants who had a longer PTA tended to have higher contusion scores and softening parenchyma (i.e., decreased stiffness compared to contralateral control) found on MRE, though did not reach a significant level due to the small sample size.
Conclusions: Identification of an objective measure of TBI severity that accurately predicts key outcomes at discharge from acute rehabilitation would provide meaningful, long-term prognostic information that could guide ongoing treatment efforts and help determine prognosis. To our knowledge, this is the first report of applying a novel MRI/MRE imaging protocol to quantitate altered brain anatomy after moderate-severe TBI, and its association with PTA, a known clinical predictor of post-acute outcome.
298 Facilitating the delivery of a group-based active rehabilitation program for youth with post-concussion symptoms
Christine Provvidenzaa, Alysha Rajaramb, Amanda Montaglianib, Hiba Al-Hakeema, Andrea Hicklinga,b, Shannon Scratcha,c,d
aBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bDepartment of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada, cDepartment of Pediatrics, University of Toronto, Toronto, Canada, dRehabilitation Sciences Institute, University of Toronto, Toronto, Canada
ABSTRACT
Background: Children recovering from persistent post-concussion symptoms (PPCS) often experience difficulties engaging in meaningful daily activities such as school, sport, and recreational activities. To promote concussion recovery, Move&Connect-Youth, a novel group-based active rehabilitation intervention for youth with PPCS, was developed to help youth learn new skills to manage their symptoms, complete active rehabilitation exercises, and meet peers with similar experiences. To facilitate Move&Connect-Youth, clinicians require the appropriate knowledge, skills, and resources to effectively deliver the intervention in a standardized fashion. As such, the purpose of this study was to: (a) assess clinician awareness of PPCS and group-based active rehabilitation methodology, (b) identify barriers and concerns related to administering Move&Connect-Youth and, (c) establish what information clinicians deem as necessary for future intervention implementation and facilitation.
Methods: Using a qualitative approach, a needs assessment was conducted through semi-structured interviews with occupational therapists (OTs), physiotherapists (PTs), occupational therapy assistants (OTAs), physiotherapy assistants (PTAs) and students within these professions. The ADDIE model (analyze, design, development, implementation, evaluation) was used to develop the interview guide to best understand the instructional resources necessary to deliver Move&Connect-Youth. Interviews were conducted and recorded using Zoom, and were transcribed and reviewed for accuracy and familiarity prior to analysis. Data were analyzed using conventional content analysis.
Results: Fifteen clinicians (OTs = 3; PTs = 4; OTAs = 2; PTAs = 2; OT student = 3; PT student = 1) with varying levels of professional experience participated in the study. It was found that more experienced participants wanted a self-directed learning approach (e.g. manual), while less experienced participants wanted a guided learning approach (e.g. shadowing). Overall, an instructional manual (n = 11) was identified as the preferred resource for assisting clinicians with intervention delivery. Participants emphasized the importance of the manual being paper-based, user-friendly (e.g. using headers, bullet point format, pictures), and accessible. Additional training opportunities identified included instructor-based training (n = 8), watching videos (n = 6) and the chance to consult with experts (n = 14). Participants felt the instructional resources should include content on topics such as the purpose and goals of Move&Connect-Youth, activities to be completed, activity modifications for individuals with different abilities and concussion symptoms, maintenance of patient safety, and best methods to facilitate the intervention with patients.
Conclusions: Understanding the learning needs of clinicians is essential in providing them with appropriate resources to facilitate clinical interventions. Creating a paper-based, user-friendly and accessible instructional manual was identified as an essential resource to help build knowledge and skill for clinicians delivering Move&Connect-Youth. Using the ADDIE model, a wireframe for the manual will be created with clinicians to develop an instructional resource that meets their needs and will help them deliver Move&Connect-Youth.
300 A decade of the northern ireland children’s acquired brain injury consultation service: a look at the past, the present, and the future
Katie Burnsa, Naomi Browna, Eunan McCrudden Eunan McCruddena
aBelfast Trust, Belfast, United Kingdom
ABSTRACT
The Children’s Acquired Brain Injury Consultation Service (Children’s ABCs) was established in 2011, following a Northern Ireland review of acquired brain injury services. This had highlighted a significant discrepancy between the adult and children’s statutory service provisions, and a lack of specific acquired brain injury services for children. Funding was made available to establish the Children’s ABCs, a ‘service facing service’ covering all five Trust areas in NI. The team is comprised of a clinical psychologist, an occupational therapist and a speech & language therapist, together making up a single whole time equivalent staff member. The key focus was to enhance already available provisions and upskill staff, via consultation and training for any staff member working with a child with an acquired brain injury, in the sectors of healthcare, education, juvenile justice, the voluntary sector or community groups. The rationale behind this innovative way of working was that, due to the nature of acquired brain injury, children were finding themselves in a multitude of different services throughout their journey. Hence, a core aim was to improve understanding of childhood ABI of a diverse range of staff to improve the quality of service these children and their families receive.
Now in its 10th year of practice, the service remains the same size with no additional funding identified, however despite the small resource, significant gains in the awareness of the needs of children with acquired brain injury have been made. The team provide training into a wide range of health and social care and education training courses, both on an ad hoc and rolling basis. Recognition is given to the need for collaborative working, and the team work closely with, and offer consultative support to, two local children’s brain injury charities, The Child Brain Injury Trust and Brain Injury Matters. Since 2012 the service has provided multidisciplinary consultation to 366 individuals, and has provided training to 1945 staff members.
The service has won local recognition, placing as a finalist in the Advancing Healthcare Awards for achievements in support and developing the Allied Healthcare Professionals workforce, and winning a Guidelines and Audit Implementation Network (GAIN) Service award, both in 2014.
The discussion will reflect on the work of the CABCS team in the 10 years since the service was commissioned. In doing this we will explore the perspective of the children’s services staff who used the service, describe how the service evolved in response to the Covid-19 pandemic, and look to the future, considering other innovative ways to support staff in all sectors who work with children with an acquired brain injury.
301 Readiness for transition to adulthood for adolescents with TBI: what we learned from a model program
Juliet Haarbauer-Krupaa
aDepartment of Pediatrics, Emory University School of Medicine, Marietta, USA
ABSTRACT
Background: Children and teens who sustain an ABI are vulnerable to disruption of new and emerging skills that impact academic functioning during school years and further influence outcomes following graduation. Because there is limited information about adult outcomes for children who experience ABI, we do not have a clear understanding of how this acquired health condition affects attainments of adult milestones such as high school graduation, enrollment in post- secondary education or obtaining employment.
School systems offer transitional plans as part of an Individualized Education Plan (IEP) for those enrolled in special education. Pediatric medical systems of care are rarely aligned with adult models of care to support the transition. Further, teens and their families may not be aware of long-term consequences of a ABI experienced as a child. The purpose of this session is to describe what was learned from the establishment of a model program that addressed both healthcare and educational/vocational areas.
Methods: In the initial year, the program focused on cognitive rehabilitation and strategies to improve learning. Following participant and family feedback, the program model expanded to provide a greater focus on self-determination and achievement of individualized short-term objectives to meet post high school goals. Program emphasis was in the area of education, time management, fitness and wellness, communication skills and based on the book, Seven Effective Habits of Highly Effective Teens. A Participatory Action Research Model, incorporating feedback from focus groups of teen participants and stakeholders (parents, physicians, educators, state agency personnel) developed the framework of the program. A peer coach model was established by incorporating college age students as peer counselors. The program strived to provide teens with strategies for improving health and academic performance, determining career goals and interests, examine existing educational programs and providing information about long term effects, driving, returning to competitive sports and utilizing technology for self-management.
Results: Overall, participants reported goals to attend college, drive, and participate in athletics. Program accomplishments included: 1) Provided recommendations for IEP revisions and development of transition plans, 2) Individuals were able to use their cell phones for time management, alerts and reminders, 3) Provided access to services and consults and 4) Provided education on the rehabilitation driving process, risk for sports related concussions and rights in IEP meetings.
Conclusion: Adolescents who experience brain injury during childhood benefit from a program that addresses their educational and healthcare needs as they transition to adulthood. Programs that include education on lasting effects, goal setting, peer coaches, fitness assessment, vocational interests and technology use provide a range of services that can facilitate this process. Long term follow-up studies of children who experience brain injury is needed to better understand transition to adulthood and achievement of optimal outcomes.
302 Psychological contributions to persistent memory symptoms after concussion: an exploratory study
Edwina Picona, Daniela Palomboa, Rebecca Todda, Noah Silverberga
aUniversity Of British Columbia, Vancouver, Canada
ABSTRACT
Introduction: It is unclear why some people experience persistent memory symptoms after a concussion in the absence of memory impairment, based on neuropsychological testing. The present study examines whether psychological factors implicated in Functional Cognitive Disorder (FCD; cognitive symptoms not attributable to brain injury/disease), including depression, memory perfectionism, anxiety, somatization, and maladaptive coping strategies may help explain persistent memory symptoms after a concussion.
Methods: Cross-sectional study of 54 participants (n = 34 with concussion and n = 20 healthy controls). Subgroups were formed based on FCD symptom severity (Functional Memory Disorder Inventory – Long Version) to compare participants with suspected FCD after concussion (n = 28) and healthy controls with no concerns about their memory (n = 13). Independent sample t-tests compared these two subgroups on depression (Patient Health Questionnaire – 9), memory perfectionism (Metamemory in Adulthood Questionnaire – Achievement scale), anxiety (General Anxiety Disorder – 7), somatization (Patient Health Questionnaire – 15), avoidance (Multifactorial Memory Questionnaire – Strategies subscale), and checking behaviors (Memory for Actions and Events Questionnaire – Obsessive/Responsible subscale). Linear regressions tested the relationships between these factors with FCD symptom severity in the full concussion sample.
Results: There were significant differences between the suspected FCD and healthy control groups on depression scores (Cohen’s d = 1.17, 95% CI: 0.46–1.87), memory perfectionism (Cohen’s d = 1.10, 95% CI: 0.39–1.76), anxiety (Cohen’s d = 1.06, 95% CI: 0.36–1.75), somatization (Cohen’s d = 1.56, 95% CI: 0.81–2.30), and one memory avoidance strategy (i.e., “asking someone to help you remember something or remind you to do something”)(Cohen’s d = 1.11, 95% CI: 0.40–1.80). In the full concussion sample (n = 34), FCD symptom severity was associated with depression (B = 0.94, 95% CI: 0.16–1.72), memory perfectionism (B = 0.94, 95% CI: 0.43–1.45), and the same memory avoidance strategy (B = 4.45, 95% CI: 0.44–8.45). There was no significant association between anxiety, somatization, or checking behaviors with FCD symptom severity in the full concussion sample.
Conclusion: This research highlights likely (e.g., depression, memory perfectionism, avoidance) and possible (e.g., anxiety, somatization) reasons why some people might develop persistent memory symptoms after a concussion in the absence of objective cognitive impairment. Longitudinal and experimental studies are needed to clarify the role of psychological factors and inform the development of new treatments for persistent memory symptoms after concussion.
303 The effects of repetitive mild traumatic brain injury in a novel Drosophila model
Amy Renniea,c, Meherunnessa Hossinb, Tamara Botoc
aNational Rehabilitation Hospital, Ireland, bNeuroscience Moderatorship, Ireland, cDepartment of Physiology, School of Medicine, Ireland
ABSTRACT
Background: Traumatic brain injury (TBI) is a major public health issue responsible for significant death and disability. Mild TBI (mTBI) accounts for 60–65% of TBI cases annually and symptoms include fatigue, anxiety, impaired cognition, headache and sleep-disturbance. There is increasing evidence that secondary neurobiological cascades post-TBI proliferate with repeated insults. These processes are linked to chronic neurodegenerative changes. Drosophila models have been central in providing insights into the pathophysiology of neurodegeneration, with broad application to human disease.
Methods: This study characterized a novel model of Drosophila repeated mTBI, using a piezoelectric TBI apparatus. The piezoelectric apparatus was successfully calibrated to reliably administer mTBI (35% head compression) to the fly heads. The mTBI protocol involved five “hits” at one-minute intervals, repeated on two consecutive days. The effects of mTBI on survival, sleep and locomotion were assessed longitudinally using established behavioral assays.
Results: Flies that received mTBI had significantly shorter lifespans than sham and control groups. The different anaesthetic methods tested (hypothermia or CO2) did not affect survival in the mTBI group. When compared to control and sham, mTBI was shown to produce a model of acute post-traumatic excessive daytime sleepiness, a widespread symptom of human mTBI. In the long-term post mTBI, excessive daytime sleepiness resolved, which also models the human course of disease. Long-term post mTBI there was a trend toward increased bouts of nighttime sleep and shorter duration of sleep bouts. This is indicative of sleep fragmentation. No significant locomotive deficits were observed acutely post mTBI between groups.
Discussion: The mTBI produced is achieved by the swift deflection of the piezoelectric actuator which causes a primary injury to the Drosophila brain. This form of injury mirrors the events which lead to closed head TBI in humans, resulting in focal and diffuse lesions. Our study demonstrated a significant short-term effect on the daytime activity levels of the mTBI flies with a corresponding significant increase in daytime sleep. This result is meaningful as one of the most prevalent sleep-wake disturbance reported acutely post TBI in humans is excessive daytime sleepiness and fatigue.
Conclusion and Future Directions: The validation of this TBI model levers future research on the cellular events mediating TBI pathology and recovery. The conservation of cellular pathways along eukaryotic cells validate Drosophila as a model organism, which is reinforced by the replication of patient-reported symptoms using our model. Future studies, based in the manipulation of key cellular pathways implicated in secondary brain injury such as the integrated stress response will be performed. This will help to further elucidate the mechanisms of recovery post mTBI, providing the groundwork for identifying potential therapeutic targets to treat the neurobiological and neurodegenerative processes triggered by mild TBI.
304 Seizure risk associated with the use of transcranial magnetic stimulation for coma recovery in individuals with disordered consciousness after severe traumatic brain injury
David Ripleya,b, Kelly Kresed, Joshua Rosenowb, Mark Conneelyd, Vijaya Patild, Stephan Scheuleb, Marilyn Pachecod,e, Elliott Rothb,f, Sandra Kletzeld, Sherri Livengoodd, Alex Aronsond, Brett Hartond, Dulal Bhaumikd,g, Runa Bhaumikg, Ann Guernond,h, Elyse Walshd, Amanda Wisingerc, Theresa Papeb,d
aHealthbridge Complex Care & Rehabilitation, Arlington Heights, USA, bNorthwestern University Feinberg School of Medicine, Chicago, USA, cChicago School of Professional Psychology, Chicago, USA, dEdward Hines Jr. VA Hospital, Hines, USA, eLoyola University Medical Center, Hines, USA, fShirley Ryan AbilityLab, Chicago, USA, gUniversity of Illinois Chicago, Chicago, USA, hLewis University, Romeoville, USA
ABSTRACT
Background: Advances in medical care have resulted in improved survival for individuals with traumatic brain injury. Concomitantly, many people now survive to live with disorder of consciousness (DoC) following traumatic brain injury. Clinicians continue to look for new treatment options for DoC. Repetitive Transcranial Magnetic Stimulation (rTMS) is an emerging treatment to improve level of consciousness for these individuals. However, there is limited evidence about the safety of this intervention for individuals with DoC.
Methods: Data derived from three separate rTMS studies that each enrolled unique participants in states of DoC after TBI were evaluated for associations with adverse events, such as seizures. Subjects received rTMS to the dorsolateral prefrontal cortex (DLPFC) in all three studies. The relationship between adverse events and rTMS was examined using logistic regression. The relationships between both seizure occurrence (SO) and each seizure risk factor/predictor variable were also examined using Pearson correlation. For the significant correlations, contingency chi-square tests were computed with the same variables to confirm significance. Variables with Pearson correlations larger than 0.25 or significant with chi-square tests were included in the logistic regression models as predictors. Specifically, a logistic regression model for each SO outcome was conducted using the group variable (Active rTMS and Placebo rTMS) and variables with correlations > 0.25 or that were significant.
Results: Three subjects were noted to have experienced seizures during the protocols. Two of the seizures occurred during the treatment phase of protocol and one during the placebo phase. Both subjects who experienced seizures during active rTMS treatment were noted to have ventriculoperitoneal shunts. One of these episodes was a subclinical seizure. There were no associations between these variables and SO-any day. There was one significant correlation with SO-rTMS day, which was the presence of a VP shunt. There were no associations with any other adverse event.
Conclusion: In this evaluation of safety of rTMS in individuals with DoC following TBI, there was no statistical difference between active and placebo groups with the occurrence of seizures. There was a strong association between the occurrence of seizure during rTMS with the presences VP shunts for hydrocephalus. rTMS appears to be safe and well-tolerated in this patient population. More evidence is needed regarding the efficacy of this intervention.
306 From neurosurgery to neuro-recovery: a case series showcasing a multimodal standard of care model already enhancing improvements in traumatic injury recovery
John Edwardsa,b, Alina Fongc, Tyler Hanakc, Jaycie Loewenc
aSummit Brain and Spine PC, Lehi, USA, bIntermountain Healthcare, Lehi, USA, cCognitive FX, Provo, USA
ABSTRACT
From the Inca practicing trepanation, to surgical treatment of head and spinal injuries during the Middle Ages in Al-Andalus, to neurosurgery for depressed skull fractures performed by doctors of the Roman Empire, humans have been researching ways to improve outcomes after trauma to the body, brain, and nervous system. With faster cars, an aging population, and other factors contributing to the rise in traumatic injury to the nervous system, methods to enhance outcomes after injury have never been more in the spotlight.
The current gold standard of neurosurgery utilizes the latest and most minimally invasive surgical techniques that allow patients to heal faster and have the best outcomes. Neurosurgeons are also beginning to collaborate with a multimodal network of practitioners and researchers, such as neuropsychologists and neuroscientists, to facilitate their patient’s recovery far beyond the operating room. Currently, medical teams have access to various pre- and post-operative techniques, such as functional neuroimaging (functional MRI, positron emission tomography, magnetoencephalography) for presurgical cognitive mapping, as well as referral structures that allow post-operative patients to receive psychologist, physical, cognitive, and other types of therapy.
In this presentation, Dr. John Edwards, MD, Neurosurgeon, will discuss the neurosurgeon’s view during complex procedures involving the brain and spine and will outline groundbreaking collaborative efforts in trauma recovery that are drastically improving recovery from traumatic injury. The audience will be educated on why advancements in the field and in the operating suite will only translate to patient outcomes when a team and contextual approach is taken to medicine.
308 Advances and best practices in the rehabilitation of long COVID autonomic nervous system dysfunction
Jaycie Loewena, Alina Fonga
aCognitive Fx, Provo, USA
ABSTRACT
Following the initial surge of COVID-19, attention has shifted to understanding and treating the longer-term sequelae caused by the virus. Months after the initial infection, patients are experiencing symptoms of fatigue, dizziness, breathlessness, chest pain, palpitations, and orthostatic intolerance despite only having mild acute symptoms. Now termed long COVID, post-acute COVID syndromes, or post-COVID symptoms, among other names, the lasting effects of COVID-19 are puzzling many due to their existence despite no abnormal findings in routine structural and functional testing.
The physiologic effects of the SARS-COV2 virus are varied and include direct viral infection of tissues as well as indirect damage to organ systems through hypoxia, inflammation, and other factors. Both direct and indirect effects of the virus can induce nervous system dysregulation, particularly in the autonomic nervous system (ANS). The ANS regulates involuntary body processes including heart rate, blood pressure, respiration, and digestion, among other functions, through a careful balance of its sympathetic and parasympathetic branches.
The relationship between COVID-19 and the ANS is complex. Autonomic disorders such as orthostatic hypotension and postural orthostatic tachycardia syndrome are associated with autoantibodies, suggesting COVID-19-induced autonomic dysfunction could be mediated by the virus itself. The ANS is also tightly linked to immune function: The pro-inflammatory immune response to the disease results from sympathetic activation. Conversely, para-sympathetic stimulation results in an anti-inflammatory response.
Many studies have shown that non-pharmacologic treatments, such as exercise training, play an important role in enhancing sympathetic/parasympathetic balance as part of a multimodal recovery plan. Forms of activities such as high-intensity interval training, breathing exercises, relaxation, and transcutaneous electrical stimulation can improve autonomic balance and are already implemented in care plans for other conditions, such as cardiac and cancer rehabilitation.
In this presentation, subjective symptom and objective functional neuroimaging data from a population of those with post-acute COVID symptoms will be described and compared to other conditions involving autonomic dysfunction, such as post-concussion syndrome. Significant symptomatic improvements as a result of a multimodal approach utilizing exercise, respiratory, vestibular, and other therapies will be shown and discussed as an indicator of the success of autonomic-targeted therapy for long COVID.
310 Reading after traumatic brain injury: a description of the literature and proposed techniques for research
Peter Meulenbroeka
aUniversity of Kentucky, Lexington, USA
ABSTRACT
Background: Reading difficulties affect employment in persons with traumatic brain injury (TBI), but there are no assessments that assess TBI-related reading deficits. An empirical assessment of the cognitive constructs underlying TBI-related reading deficits and an essential need to apply this knowledge to workplace functions. First, we will describe the Construction-Integration (CI) model of reading research and models of coherence in reading in neurotypicals, as well as how they relate to eye movements in everyday reading tasks. Second, we will discuss the role of working memory and visuomotor deficits associated with TBI and how these can impact everyday reading ability. Third, we will describe how eye-tracking can provide insight into cognitive effort associated with working memory while reading functional work-related materials. We will present preliminary evidence from empirical research using eye-tracking as it either supports or refutes proposed models and/or methods, as well as how it relates to functional reading requirements.
Methods: We will examine the degree of effort demanded by working memory through the use of eye-tracking measures (eye fixation, saccade length, and reading rate). We will use established stimuli for semantic disambiguation tasks. The SCOLP is a sentence-length measure of reading rate, O’Brien and colleagues (Albrecht & O’Brien, 1993) developed a lengthy paragraph paradigm for examining the role or working memory in global and local coherence in reading (or discourse). Results will be interpreted within the context of a CI reading model. The paragraph passages will always be locally coherent, with coherence disruption occurring when the critical sentences are inconsistent or non-sensible with the preceding text.
Results: No data has been collected to date. If pilot data is available, then we will present on sentence, paragraph, and multi-paragraph level reading paradigms described above. An IRB approval from the University of Kentucky has been granted, and final efforts on programming the eye tracker are currently being executed. We predict that at the time of the conference, we will have preliminary data from a small sample – approximately 5–10 persons with mild TBI and 5–10 healthy controls.
Conclusions: Reading is an important part of everyday adult life. Reading requires the reader to develop a model of information as they read. As the read material lengthens, demands are placed on working memory to link local information with information previously read (i.e. local and global coherence). This reflects a process similar to executive functioning. By examining working memory, we might be able to understand TBI-related reading deficits as related to a working memory capacity limitation. This will help inform future assessment and treatment of the disorder.
311 Evaluating a novel cognitive behavior therapy intervention for sexuality changes after traumatic brain injury: a single case series
Elinor Frasera,b, Marina Downinga,b, Kerrie Hainesa, Linda Bennetta, John Olverc, Jennie Ponsforda,b
aTurner Institute for Brain and Mental Health, Monash University, Clayton, Australia, bMonash-Epworth Rehabilitation Research Center, Epworth Healthcare, Richmond, Australia, cRehabilitation Medicine, Epworth HealthCare, Richmond, Australia
ABSTRACT
Background: More than half of adults with traumatic brain injury (TBI) report sexual dysfunction and/or poor sexual wellbeing post-injury. Despite widespread awareness that sexuality changes persist long term, no evidence-based interventions exist to promote positive sexual adjustment after TBI.
Objectives: Using both quantitative and qualitative methods, this study aimed to evaluate the efficacy, feasibility, adherence, and acceptability of CBT-SWELL, a novel, individualized Cognitive Behavioral Therapy treatment for Sexual-WELLbeing after TBI.
Method: A nonconcurrent multiple baseline single-case experimental design with an 8-week follow-up phase and randomization to multiple baseline lengths was repeated across nine participants (5 female) with moderate to severe TBI (mean age = 40.44-years (SD = 14.15), mean PTA = 34.50-days (SD = 29.25), mean time post-injury = 7.92-years (SD = 11.09)). The primary outcome measure was a rating scale measuring participants’ subjective satisfaction with their sexuality completed three times weekly. Secondary outcome measures of mood, self-esteem, social participation, and functional goal attainment were also completed at three time points (pre-treatment, post-treatment, follow-up). Offered to both individuals and couples, CBT-SWELL comprised eight weekly, individual sessions and one booster session with a clinical psychologist. The CBT-SWELL treatment guide was organized into 12 modules with accompanying handouts. The overarching aims of CBT-SWELL were to (1) foster shifts in cognition and/or behavior that allow individuals/couples to feel more in control of their sexuality, (2) improve satisfaction with sexuality in the individual with TBI, and (3) help individuals with TBI accept and manage changes in sexuality.
Results: Quantitative results provided preliminary support for the efficacy of CBT-SWELL, with 5 participants showing improved sexuality satisfaction post-treatment, and an additional 3 participants demonstrating delayed treatment response, with improved sexuality satisfaction reported at follow up. All participants demonstrated clinically significant improvement in at least one goal. Adequate treatment adherence and good feasibility were also shown. Qualitatively, participants experienced multiple benefits from the treatment, with high levels of enjoyment, satisfaction, and acceptability reported. The unique participant perspectives illustrated in this research not only provide valuable insight into the experience of the intervention but offer important considerations for future research.
Conclusions: The results offer preliminary evidence of efficacy for CBT-SWELL in treating complex and diverse sexuality problems after TBI, with larger trials warranted.
313 Translating concussion evidence into educational resources: the concussion awareness training tool (CATT)
Shelina Babula,b
aBC Children’s Hospital, Vancouver, Canada, bUniversity of British Columbia, Vancouver, Canada
ABSTRACT
Introduction: Concussions occur inside and outside of the sports realm, including those resulting from falls, motor vehicle crashes, and violence. The diverse concussion education needs extend beyond medical professions, coaches, youth, athletes, and their caregivers, to include educators, workers and their employers, and those supporting the survivors of intimate partner violence.
Approach: The Concussion Awareness Training Tool (CATT) provides free up-to-date concussion information. The online modules and resources are evidence-based, created using an integrated knowledge translation approach with each target audience. CATT resources include the Concussion Pathway, also adapted for workers in the Motion Picture, Film, and Live Performance industry, as well as for neurodiverse students; questions to ask your doctor; return to activity, school, school, and work strategies; accommodations following concussion; and a resource for managing mental health symptoms. This widespread approach to concussion education was launched in 2013 and continues to grow. Recognized by the Canadian Concussion Harmonization Project, the Public Health Agency of Canada, and Parachute (Canadian injury prevention NGO), CATT modules are also available in French. Global education efforts using CATT have focused on East Africa (Uganda, Kenya, Tanzania), Pakistan, Japan, Lebanon, and New Zealand. Uptake: CATT training has been mandated by over 75 sporting associations, universities, schools, and other organizations. Most notable are the BC Hockey Association (i.e., 14,000 on-ice officials) and BC School Sports (i.e., 450-member schools). CATT for high performance athletes has been mandated by 27 Canadian universities, 1 college in the United States, and three sports organizations. The cattonline.com website receives over 8,000 visits per month from over 50 countries: primarily Canada and the United States, as well as the United Kingdom, Australia, China, New Zealand, Ireland, India, South Africa, France and elsewhere. From 2021 to 2022, the number of annual number of users on the CATT website grew from 45,538 to 81,613; the number of sessions grew from 72,830 to 123,978; and the number of page views grew from 226,588 to 406,087. To date, over 100,000 people worldwide have completed CATT training. Completions of the CATT eLearning modules from May 2018 to August 2022 included: 27,302 coaches, 7,554 school professionals, 2,957 medical professionals, and 2,901 parents and caregivers. Since 2019, there have been 813 completions by workers and workplaces; and since 2020, there have been 21,906 completions by university/college level athletes, and 666 women’s support workers. The newest CATT module for Youth was launched in September 2022.
Next Steps: The CATT educational modules and resources will undergo review following the 6th International Consensus Conference on Concussion in Sport being held in late October 2022. Plans are also underway to update the CATT online platform, as well as to engage with Indigenous partners to create culturally appropriate concussion resources.
315 The validation of the SWADOC: a multicenter prospective cohort study
Amandine Regniera,b,c, Laurence Pirnayc, Nicolas Lejeunea,b,d, Valérie Chavete, Céline Aussemsf, Aurore Thibauta,b, Jean-François Kauxc, Evelyne Mélottea,b,c, Olivia Gosseriesa,b
aUniversité de Liège, Vierset-Barse (Modave), Belgium, bCentre du Cerveau, University Hospital of Liège, Liege, Belgium, cPhysical and Rehabilitation Medicine Department, University Hospital of Liège, Liege, Belgium, dCentre Hospitalier Neurologique William Lennox, Groupe Hospitalier Saint-Luc, Ottignies-Louvain-la-Neuve, Belgium, ePhysical and Rehabilitation Medicine Department, Center of Traumatology and Readaptation Erasme, Brussels, Belgium, fNeurology Department, Valdor Clinic, Liege, Belgium
ABSTRACT
Background: After a severe brain injury and a period of coma, some patients may develop disorders of consciousness (DoC). Severe dysphagia is present nearly systematically in these patients, leading to major functional consequences and comorbidities. Assessment and swallowing therapy in patients with DoC are therefore essential aspects of their management.
Methods: We will conduct a multicenter prospective cohort study. One hundred and four patients with DoC will receive behavioral measure at baseline with the Coma Recovery Scale-Revised (CRS-R) followed by three sessions combining consciousness assessment with the Simplified Evaluation of CONsciousness Disorders (SECONDs) and swallowing assessment with the SWADOC within five working days. Internal consistency, test-retest reliability, concurrent validity (with the Facial Oral Tract Therapy Swallowing Assessment of Saliva – FOTT-SAS), intra-judge reliability, inter-judge reliability and the links between the SWADOC-scored and the level of consciousness will be assessed.
Results: Preliminary results will be presented at the conference. We expect that the SWADOC is a reliable and valid scale, and that the subscores (oral phase and pharyngeal phase) and the total score are related to the patient’s level of consciousness.
Conclusion: This study aims to validate the SWADOC as a reliable bedside tool for swallowing assessment in DoC patients and to give a better understanding of relationship between consciousness and swallowing components. These results may help the development of new diagnostic guidelines for DoC that would include swallowing components in their criteria.
316 Using participatory design to co-create technological tools to support online social participation among adults with traumatic brain injury (TBI)
Hajin Lima, Lisa Kakongeb, Yaxin Huc, Lyn S. Turkstrab, Melissa C. Duffd, Catalina Tomae, Bilge Mutluc
aDepartment of Communication, Seoul National University, Seoul, South Korea, bSchool of Rehabilitation Science, McMaster University, Hamilton, Canada, cDepartment of Computer Sciences, University of Wisconsin-Madison, Madison, USA, dDepartment of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, USA, eDepartment of Communication Arts, University of Wisconsin-Madison, Madison, USA
ABSTRACT
Background and Objective: A substantial body of research has outlined the functions and benefits of social media as a tool for social participation, with emerging evidence that social media can also benefit adults with traumatic brain injury (TBI). Social media platforms like Facebook may help people with TBI to build and maintain social connections; reduce loneliness and isolation; and increase access to information and support. However, individuals with TBI report using social media less frequently than their uninjured peers and encountering accessibility and usability challenges, and most social media platforms were not built to accommodate the needs of those with lived experience of TBI. The purpose of this study was to gain in-depth understanding of how adults with TBI use social media, and elicit their ideas and feedback about technological tools that would help them use social media as they wished. This study was part of the Social Building Blocks Online project, which aims to develop technology solutions to support the online social participation of adults with TBI.
Methodology: We conducted remote semi-structured interviews and participatory design (PD) sessions with 10 adults in the chronic stage after TBI, focusing on their use of Facebook, which research shows is the most popular platform among individuals with TBI. PD sessions included three central activities: (1) Exploration Stage: participants engaged in an in-depth interview and think-aloud activity about their Facebook use and specific challenges encountered on Facebook; (2) Ideation Stage: participants were guided to identify design goals to address Facebook challenges; and (3) Sketching Stage: participants sketched design solutions for identified challenges.
Data Analysis: Thematic analysis was conducted to identify how each participant-generated design idea linked to various TBI-related challenges and barriers to Facebook use. RESULTS: Four themes and related design solutions emerged: 1) interface, feature, and information overload; 2) Facebook as a source of negativity and social comparisons; 3) self-presentation concerns related to TBI; and 4) reduced perceived confidence in communication. Additionally, participants described reducing their Facebook activity post-injury due to sensory, cognitive, and communication difficulties; struggles with reconciling their post-TBI identity and fear of online self-disclosure; Facebook-related privacy concerns; and difficulties re-adjusting to interface and updates of social media platforms. Novel design ideas from participants included Facebook providing pre-loaded comments to support social communication, and a “safe-filter” mechanism for the Facebook feed to filter out unwanted or triggering posts.
Conclusion: The study revealed that individuals with TBI faced significant TBI- and Facebook-related challenges and these challenges had a negative effect on Facebook use. The results provide insight into how people with TBI may benefit from enhanced features on social media platforms. Our work contributes to designing technological tools to improve the accessibility of social media for people with TBI.
317 Effects of photobiomodulation treatment on motor performance and underlying resting state functional connectivity of the cerebellum in adults with a history of repetitive head impacts: a feasibility study
Paula Johnsona,b,c, Hannah Lindseya,b, Carrie Esopenkoa,d, Mary Newsomea,e,f, Finian Kelehera, Peter Finoa, Elizabeth Hovendena,b, Ryan Peloa, Amanda Morrisa, Nicholas Kretera, Lance Davidsona,c, Tanner Guderiana, Hilary Russella,b, Emma Reada, Dayna Thayna,c, Carmen Veleza,b, Christine Mullena, Michael Larsonc, Spencer Liebela,b, Lawrence Carra, Elisabeth Wildea,b,f
aUniversity of Utah, Salt Lake City, USA, bGeorge E. Wahlen VA Medical Center, Salt Lake City, USA, cBrigham Young University, Provo, USA, dICAHN School of Medicine at Mount Sinai, New York, USA, eMichael E. DeBakey VA Medical Center, Houston, USA, fBaylor College of Medicine, Houston, USA
ABSTRACT
Repetitive head impacts (RHI) are subtle blows to the head during athletic activity that over time may result in chronic motor impairments, including decreased reaction time, deficits in balance, and altered gait. For decades, photobiomodulation (PBM), formerly known as low level laser therapy, has been used for wound healing; however, emerging technology now makes it possible to safely deliver light to the brain via a relatively inexpensive, easy to use, LED headset. Though used to treat cognitive and psychological symptoms following traumatic brain injury, the reported cellular mechanisms of PBM–enhanced circulation, improved mitochondrial function and ATP production, and reduced inflammation – have systemic effects that make it a candidate for improving motor performance. In the present feasibility study, we tested and treated individuals exposed to RHI to investigate the potential for PBM to reduce the risk of long-term motor declines and improve the underlying functional connectivity of the brain. The present study included 30 patients (28 male) between the ages of 22–69 (M = 46.3 ± 15.2) with a self-reported history of RHI exposure [between 4–30 (M = 13.3 ± 6.7) years]. Exclusion criteria included a history of neurologic disease or psychiatric disorder and MRI contraindications. An at-home PBM headset was used for 20 minutes, 3–5 times per week over the course of 8–10 weeks. The device emits 25 milliwatts of NIR light to the frontal and frontoparietal lobes. Additionally, an intranasal probe was used simultaneously to deliver NIR light to subcortical structures and the orbitofrontal cortex. Combined, these lights deliver a total of 240 J/cm2 pulsed at 40 Hz. Motor function was assessed using standard clinical measures of simple reaction time, dexterity (Grooved Pegboard Task), grip strength, and dynamic balance (Mini-BEST), while seed-based resting-state functional connectivity (rsFC) was assessed using resting-state fMRI before and after the PBM intervention. Within-group comparisons of change in motor function and rsFC over time were performed. Pre-to-post PBM intervention change scores for each motor measure, as well as rsFC parameter estimates for cerebellum network seeds were calculated. Exploratory correlational analysis was then used to investigate the relationship between changes in motor function and changes in rsFC following the intervention. Following the PBM intervention, we observed significant improvements in simple reaction time, grip strength, and dynamic balance. Results of the correlational analysis suggest that improvements in simple reaction time and dexterity are associated with changes in rsFC in anterior regions of the cerebellum, whereas improvements in balance performance are associated with changes in rsFC of the posterior regions. These findings have promising implications for the use of PBM in treating potential chronic sequelae of RHI related to motor function, namely through alterations in underlying brain physiology.
318 Teaching educators about acquired brain injury: improvements in confidence and self-efficacy through an online professional development module
Sara Marshalla,b, Brendan Lama,c, Andrea Hicklinga,d, Shannon Scratcha,e,f,g
aNOvEL Lab, Bloorview Research Institute, Toronto, Canada, bMcGill University, Montreal, Canada, cYale University, New Haven, USA, dDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, eRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, fHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, gDepartment of Pediatrics, University of Toronto, Toronto, Canada
ABSTRACT
Background: Acquired Brain Injury (ABI) is the leading cause of death and disability in young children and can result in persisting cognitive, physical, behavioral, and emotional difficulties. However, many educators have limited or only some knowledge of ABI and its consequences for a child. This limited knowledge may have a negative impact on educator confidence and self-efficacy supporting students with ABI in the classroom. In the Ontario, Canada education system, ABI is not a recognized exceptionality, creating a barrier for the identification and support of students with ABI. Following research that found limited online resources for educators, an online professional development module, Teach-ABI, was developed by our team. Teach-ABI takes a case-based approach and defines ABI, reviews ABI symptoms and how they might present in school, and outlines practical strategies educators can use to support students with ABI in the classroom. This abstract focuses on Teach-ABI’s impact on educators’ confidence and self-efficacy in supporting students with ABI.
Method: 50 teachers from Ontario public and private schools took part in this study over Zoom. Participants completed a set of surveys (ABI knowledge questionnaire, knowledge application case study, self-efficacy questionnaire) at three time points: before completing the module (T1), immediately after completing the module (T2), and 60 days after completing the module (T3). 29 participants also participated in a semi-structured interview about their experience with the module. Through deductive content analysis, concepts related to participants’ confidence and self-efficacy were examined, and salient quotes related to these outcomes of interest were extracted.
Results: Participants’ confidence in their ABI knowledge and their ability to support students in the classroom increased significantly from T1 to T2 (Z = −10.5, p < 0.001) and from T1 to T3 (Z = −10, p < 0.001), with no differences between T2 and T3 (n.s.). Salient quotes reflect that the strategies, resources, and examples made the module information easily applicable to daily life, that relating module content to personal experiences put the strategies in context, and that knowledge improvement impacted participant confidence. Participants also suggested that the module presents an ideal situation and that more case studies or examples would improve the applicability of the strategies to their teaching.
Implications: This promising pilot study indicates that the Teach-ABI online professional development module has a lasting, positive impact on educators’ confidence supporting students with ABI. In the future, we aim to make these resources accessible to teachers in Ontario and elsewhere to improve outcomes for students with ABI.
319 Memory and psychosocial reintegration in adults with moderate-severe traumatic brain injury
Sophia Kekes-Szaboa, Sharice Cloughb, Melissa Duffc
aVanderbilt University Medical Center, Nashville, USA, bVanderbilt University Medical Center, Nashville, USA, cVanderbilt University Medical Center, Nashville, USA
ABSTRACT
Objective: Memory disruption in individuals with traumatic brain injury (TBI) presents significant challenges for community reintegration following injury. However, few studies have explored the association between memory and psychosocial adjustment. We investigated the concurrent relationships of a measure of everyday memory failures with a measure of psychosocial outcome in individuals with moderate-severe TBI.
Method: Participants were 89 adults (50 females) with moderate-severe TBI. To conservatively reduce effects of developmental change and age-related cognitive decline, we restricted age to 20–55 years (M = 38 years, SD = 11.2). Average education was 14.5 years (SD = 2.6). Participants were in the chronic phase of injury, with time post injury (TPO) ranging from 6 months to 15 years (M = 3.6 years, SD = 3.4). Psychosocial outcome was assessed with the Sydney Psychosocial Reintegration Scale (SPRS-2) Form A – Self version. Degree of self-reported memory failure was assessed with the Everyday Memory Questionnaire (EMQ). We used stepwise multiple regression to predict SPRS-2 scores from EMQ and demographic variables (TPO, age, education). We compared nested models with an F-test to determine whether additional predictor models improved model fit. We conducted exploratory Pearson’s correlations between EMQ scores and the three SPRS-2 subscales.
Results: The most parsimonious model predicts SPRS-2 scores as a function of EMQ and injury TPO. Self-reported memory failures significantly predict psychosocial reintegration scores (B = −0.46, t = −8.32, p < 0.001); for every one unit increase in EMQ scores, SPRS-2 scores decreased by 0.46, while holding TPO constant. TPO also significantly predicted SPRS-2 (B = −0.04, t = −2.34, p = 0.02); For every one month increase in TPO, SPRS-2 scores decreased by 0.04, while holding EMQ scores constant. This model accounts for 45.3% of the variance in SPRS-2, whereas a simple linear regression predicting SPRS-2 from only EMQ scores accounted for 42.5% of the variance in SPRS-2 scores. More complex models including education or age as an additional predictor variable did not significantly improve model fit and were rejected. Pearson’s correlations indicated that scores from all three SPRS-2 subscales were highly negatively related to EMQ scores. Occupational Activities and Leisure (r = −0.59, t = −6.90, p < 0.001; 95% CI[−0.71,-0.44]), Interpersonal Relationships (r = −0.57, t = −6.48, p < 0.001; 95% CI[−0.70,-0.41]) and Independent Living Skills Scores (r = −0.62, t = −7.40, p < 0.001; 95% CI[−0.73,-0.47]) all tended to decrease with more self-reported memory failures.
Conclusion: Individuals with TBI who self-reported more memory failures had poorer psychosocial reintegration outcomes. Further, participants with longer TPO tended to have worse reintegration outcomes. This suggests that participants with memory disruption are at increased risk for community reintegration difficulties. These findings highlight the importance of characterizing levels of psychosocial outcome and changes over time following brain injury, with a focus on memory abilities. Environmental and compensatory interventions that support functional and everyday memory ability aimed at improving psychosocial reintegration and long-term community outcomes are warranted.
320 Influence of immigration status on the trajectory of functional independence over the 10 years after traumatic brain injury: a model systems study
Chimdindu Ohayaghaa, Paul Perrinb,c, Juan Carlos Arango Lasprillad, Shawn Jonesa
aVirginia Commonwealth University, Richmond, USA, bUniversity of Virginia, Charlottsville, USA, cCentral Virginia Veterans Affairs Medical Center, Richmond, USA, dBioCruces Health Research Institute. Cruces University Hospital, Barakaldo, Spain
ABSTRACT
Background: Although racial/ethnic disparities have been documented in numerous outcomes after traumatic brain injury (TBI), research has yet to explore differences in rehabilitation outcomes for immigrants relative to U.S.-born individuals. The purpose of this study was to compare the functional outcomes over the first 10 years after TBI for individuals born in the U.S. to those who had immigrated to the U.S.
Method: A sample of 10,695 individuals in the TBI Model Systems database with a coding for country of birth = U.S. (N = 9,435) vs. Other than the U.S. (N = 1,260) was used. Outcome measures at 1, 2, 5, and 10 years after TBI included the Motor and Cognitive subscales of the Functional Independence Measure and the Supervision Rating Scale.
Results: Immigrants exhibited lower motor functional independence trajectories than those born in the U.S., even after controlling for demographic and injury-related covariates. However, immigrants generally showed a stronger upward quadratic trajectory in motor functional independence with the greatest gains between the 5- and 10-year time points, whereas those born in the U.S. improved more quickly but then plateaued between the 5- and 10-year time points; these differential effects over time dissipated with the addition of demographic and injury-related covariates. Immigrants also exhibited lower cognitive functional independence trajectories, as well as greater supervision needs trajectories, than those born in the U.S., even after controlling for demographic and injury-related covariates.
Conclusion: These findings dovetail with literature suggesting that racially/ethnically diverse groups exhibit reduced functional independence after TBI. The findings may also suggest potential systematic barriers such as healthcare access and language barriers that influence the frequency, rate, and quality of care received. The results highlight the importance of uncovering cultural distinctions and can aid in facilitating research examining immigration-based disparities following TBI.
321 Randomized controlled trials do not adhere to focal muscle spasticity guidelines: a systematic review
Edwina Sutherlanda,b, Bridget Hilla,b, Barby Singerc,d, Stephen Ashforde,f,g, Brian Hoareh,i, Tandy Hastings-Isonj, Klemens Fheodoroffk, Steffen Berwickl,m, Gavin Williamsa,b
aEpworth Healthcare, Richmond, Australia, bUniversity of Melbourne, Parkville, Australia, cCentre for Training in Subacute Care, Fremantle Hospital, Australia, dEdith Cowan University, Joondalup, Australia, eNorthwick Park Hospital, Harrow, United Kingdom, fUniversity College London Hospitals, London, United Kingdom, gKing’s College London, London, United Kingdom, hLa Trobe University, Bundoora, Australia, iMonash University, Clayton, Australia, jRoyal Children’s Hospital, Parkville, Australia, kGailtal-Klinik, Hermagor, Austria, lSch€on Clinic Vogtareuth, Vogtareuth, Germany, mvon Hauners’ Children’s Hospital, Munich, Germany
ABSTRACT
Objectives: To determine the extent to which current randomized controlled trials (RCT) adhere to a synthesis of guideline recommendations to improve functional outcomes amongst adults with focal spasticity. Data sources: Seven electronic databases were searched for papers published from 2010.
Study selection: Randomized trials were included if they (1) targeted focal spasticity (2) included botulinum toxin-A (3) randomized a physical intervention to the upper or lower limb OR (4) the primary aim related to the activity/participation domains of the International Classification of Functioning.
Data Extraction: Two independent reviewers performed data extraction, as well as quality appraisal according to the Modified PEDro and Modified McMasters Qualitative Review. General research principles were also extracted such as study registration, use of CONSORT guidelines, use of clinical guidelines, TIDieR checklist and protocol publication.
Data synthesis: Twenty-nine RCTs met the inclusion criteria. SMART goal setting was rarely included (n = 5). Not all studies included a measure of focal spasticity, nor a measure of active function despite it being a study aim. One (3%) RCT included patient education. Despite the long-term nature of spasticity management, only 2 studies measured outcomes beyond 6 months. Eight RCTs (28%) incorporated a focal spasticity guideline in their methodology. One RCT used the CERT/TIDIER guidelines. The average Modified PEDro score was 9.9. The average Modified McMasters score was 12.5.
Conclusions: Adherence to focal spasticity guidelines in RCTs was generally low, in addition to low adherence to general research principles. Improving these two key areas may lead to a greater understanding of the relationship between improvements in focal spasticity and its translation to greater functional outcomes.
322 Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a retrospective single-center study
Jennifer Batha,b, Ellen Harveyb, Bryan Collierb,c,d, Justin Weppnera,b,c,d
aCarilion Clinic Brain Injury Center, Roanoke, USA, bCarilion Clinic, Roanoke, USA, cVirginia Tech Carilon School of Medicine, Roanoke, USA, dEdward Via College of Osteopathic Medicine, Blacksburg, USA
ABSTRACT
There were approximately 223,050 TBI-related hospitalizations in 2018 and 60,611 TBI-related deaths in 2019. People aged 75 years and older had the highest numbers and rates of TBI-related hospitalizations and deaths. This age group accounts for about 32% of TBI-related hospitalizations and 28% of TBI-related deaths. Because patients with severe traumatic brain injury lack the capacity to make medical decisions, relatives and medical teams must frequently estimate patients’ preferences for treatment, including life support. Decisions to withdraw life-sustaining therapies are usually based on perceptions of unfavorable prognosis for meaningful neurologic recovery. However, there are relatively few accurate and useful prediction tools to inform such estimates of prognosis. Therefore, prognostication is often based on clinicians’ impressions and past experiences. The subjective nature of neuro-prognostication may lead to variability in the incidence of death associated with the withdrawal of life-sustaining therapy. Hospital mortality is variable and may be explained, at least in part, by variability in the rate of withdrawal of life-sustaining treatment at institutions. This study aimed to determine if the withdrawal of life-sustaining care for persons with severe traumatic brain injury at our organization is associated with known indicators for poor prognosis. This retrospective descriptive study uses a data collection tool reviewing all TBI mortality between 8/1/18-7/31/21 in patients ages ≥ 18. A trauma registry query provided several data points for analysis. Data points not found in the registry were hand collected from the electronic health record. Logistic regression on the withdrawal of life-sustaining care will be conducted using all the recorded data fields with complete patient information. This analysis will allow the researchers to determine whether each field impacted the outcome variable and any combined impact from the fields in the model. Data abstraction is still in process but will be completed with data analysis by the end of 2022. The goal is to determine if the withdrawal of life-sustaining care is associated with known indicators of poor prognosis. We hypothesize that we do not utilize known indicators of poor prognosis and that other factors may influence the withdrawal of care decisions. If our hypothesis is supported, the research team will develop an evidence-based tool for the critical care team to use to determine if patients have indicators of prognosis and present the tool at the IBIA World Congress on Brain Injury.
323 Validation of music therapy assessment tool for awareness in disorders of consciousness (MATADOC) with the coma recovery scale-revised (CRS-R)
Wendy Mageea, Ajit Narayananb, Rebecca O’Connorc, Fiona Haugheyc, Erin Wegenerd, Bernice Chue, Mark Delargyc, Dee Grayc, Alika Seud, Richard Siegertb, Kudret Yeldenf, Rosanne Tyase, Caroline Schnakersf
aTemple University, Philadelphia, USA, bAuckland University of Technology, Auckland, New Zealand, cNational Rehabilitation Hospital, Dublin, Ireland, dSpectrum Health, Grand Rapids, USA, eRoyal Hospital for Neuro-disability, London, UK, fKing’s College Hospital NHS Trust, London, UK, gCasa Colina Hospital and Centers for Healthcare, Research Institute, Los Angeles, USA
ABSTRACT
Music interventions are a potential treatment for awareness in Prolonged Disorders of Consciousness (PDoC). Music provides a salient stimulus with emotional and biographical characteristics and has been associated with improved measures of awareness. The MATADOC is a standardized music-based protocol and assessment of awareness in people with PDoC with good inter-rater and test-retest reliability and good internal consistency. Preliminary testing suggests the MATADOC may have good agreement with the criterion standard CRS-R for diagnostic outcomes and function as a companion assessment. However, the MATADOC’s validity with the CRS-R remains untested. Gaining clarity on its validity with the CRS-R will identify the contribution that the MATADOC may make to interdisciplinary care of PDoC patients.
Research Objectives: i) To examine the concurrent validity of the MATADOC and CRS-R for outcomes of awareness. ii) To explore the function of comparable items between measures across similar domains (e.g. auditory, visual).
Design: Prospective multisite cohort study collected concurrent MATADOC and CRS-R data using repeated measures with patients with PDoC. Raters were blinded.
Setting: Three specialist inpatient rehabilitation units for PDoC (USA, UK, Ireland).
Participants: 74 adults with PDoC stemming from acquired brain injury were recruited using convenience sampling.
Interventions: The MATADOC protocol elicits behavioral responsiveness using live music in five tasks during four clinical contacts of 15–30 minutes duration (60–120 mins total). Observed behavioral responses were rated across motor, communication, arousal, visual and auditory domains using the MATADOC 14-item measure. The CRS-R protocol delivers tasks in the motor, visual, auditory and communication domains in clinical contacts of 15–30 minutes duration (60–120 minutes in total for 4 contacts) rating responses in six function scales.
Results: Fair (Cohen’s kappa or “k” = 0.238, p = 0.006) ranging to moderate (k = 0.419, p < 0.001) significant agreement found between CRS-R and MATADOC diagnostic outcomes for each contact, with significant correlations between scores (mean Pearson = 0.721, p < 0.001). The greatest agreement was for Minimally Conscious State (MCS) outcomes. Agreement increased over repeated contacts. Moderate agreement found for overall diagnostic outcomes ranging across Vegetative State (VS), MCS and Emergent from MCS (EMCS) (k = 0.397, p < 0.001). Moderate significant agreement found between measures for motor scores (k = 0.556, p < 0.001) and visual outcomes (mean k = 0.326). No agreement was found for item outcomes assessing auditory responsiveness.
Conclusion: Diagnostic outcome differences may be explained by how the two measures score auditory responsiveness: the MATADOC categorizes auditory localization as MCS in line with recent recommendations, whereas the CRS-R currently categorizes auditory localization as VS. The MATADOC may be useful for identifying cases that are responsive to auditory stimuli in the absence of other responsiveness to inform treatment decisions The MATADOC complements the CRS-R in the assessment of DOC and is useful for identifying auditory responsiveness across VS, MCS and EMCS.
324 C-reactive protein/albumin ratio (CAR) for the prediction of long-term clinical outcomes in patients with mild traumatic brain injury
Eujene Junga, Jeong Ho Leea, Sang do Shina, Young sun roa
aChonnam National University Hospital, gwangju, 대한민국
ABSTRACT
Introduction: The CRP albumin ratio (CAR), a novel inflammation-based prognostic score, is useful in predicting clinical outcomes, including those in central nervous system diseases. However, no report has identified the relationship between CAR and long-term clinical outcomes in patients with mild TBI (mTBI). We aimed to evaluate the relationship between CAR and long-term functional outcomes in patients with mTBI and analyze whether CAR is associated with the presence of fever.
Methods: This was a retrospective observational study on adult patients with mTBI who were transported to a level-1 trauma center between 2017 and 2021. The main exposure variable was an elevated CAR, and the main outcomes were degrees of disability and quality of life measured using the modified Rankin scale (mRs). A multivariable logistic regression analysis was performed to estimate the effect size of CAR on study outcomes. An interaction analysis was performed between CAR and fever on study outcomes.
Results: Elevated CAR had no significant association with poor functional outcomes (aOR [95% CI]: 1.35 [0.39–4.69]). In the interaction analysis, elevated CAR was not associated with increased poor functional outcomes in the absence of fever (1.08 [0.55–2.13]), but a significant increase in poor functional outcomes was observed when elevated CAR was accompanied by fever (1.32 (1.14–2.56)).
Conclusions: Elevated CAR with fever increased the risk of poor functional recovery at 6 months after hospital discharge in patients with mTBI. Our study findings form the basis of suggesting the need for strategies for the prevention of long-term poor functional recovery in the presence of CAR elevation and fever in patients with mTBI.
326 A potential model for telephysiatry consult services
Natalia Miranda Cantellopsa, Alison Lowrana, Amy Kolarovaa
aProvidence Health and Services, Anchorage, USA
ABSTRACT
Providence St. Elias Specialty Hospital, in partnership with Providence Alaska Medical Center, is currently piloting a telephysiatry/brain injury virtual consult service in the state of Alaska. While this program is in its initial stages, the goal is to establish a regional model to virtually serve areas in which there is limited access to brain injury medicine subspecialists, offering video-enabled consults in the ICU, medical/surgical floors, and the long-term acute care hospital in Anchorage. Consults at the pilot site are conducted using telemedicine carts shared with the telestroke program, with nursing staff assisting in the basic neurologic exam and documentation completed in the patient’s electronic medical record. The use of telemedicine services has expanded in recent years, creating a positive impact on access to care and initial data showing improvements in outcome from other domains. This can provide some insight into the potential benefits of acute teleconsultation services.
Prior to the COVID-19 pandemic, telestroke services were used in acute care hospitals and emergency departments with the goal of improving the evaluation and care of patients presenting with acute stroke symptoms, allowing immediate intervention and assessment following the stroke pathway. From an outpatient perspective, review articles have shown the effectiveness of telerehabilitation services for musculoskeletal disorders and post-stroke individuals. Additionally, studies comparing in person vs telerehabilitation services found that it did not lead to inferior outcomes and has promoted an increase in satisfaction with clinical professionals and patients. During the pandemic, many medical services were decreased or unavailable, with rehabilitation services in the outpatient setting being significantly impacted for in-person appointments. This led to a notable increase in the integration of telemedicine in medical practices and has increased the role of rehabilitation services.
The purpose of this telephysiatry consult model is to increase access to best practices in brain injury care during the acute hospital stay. The goal is to further build out the model to provide regional care in the state and offer a framework for developing this model in other areas with limited access to brain injury medicine. There is promising evidence from previous data, including the telestroke protocol and outpatient telerehabilitation services, to support the initiation of acute care telephysiatry brain injury consults. We believe that implementing telephysiatry consults in the acute care environment will provide patients with adequate rehabilitation care in a timely manner, easing the way for appropriate post-acute care and improving overall outcomes for brain injury survivors.
327 Does change in psychosocial function mediate motor and cognitive functional gains from neurorehabilitation?
Georgina Manna,b, Lakkhina Troeunga, Kris Singha,c, Curtis Redella, Angelita Martinia,b
aBrightwater Care Group, Inglewood, Australia, bUniversity of Western Australia, Crawley, Australia, cSir Charles Gairdner Hospital, Nedlands, Australia
ABSTRACT
Background: Psychosocial functions, such as emotional adjustment, social connection and capacity for self-care, are important for engagement with rehabilitation processes after acquired brain injury. Research has yet to determine whether improvements in this capacity impacts on functional outcomes.
Objectives: To examine change in functional independence via change in psychosocial function from admission to discharge from a community-based post-acute neurorehabilitation service in Australia, 2011–2020
Methods: Retrospective cohort study of n = 324 adults with traumatic and non-traumatic acquired brain injury enrolled in post-acute neurorehabilitation. Functional independence was assessed with the UK Functional Independence and Assessment Measure and psychosocial function as assessed with the Mayo-Portland Adaptability Inventory. Multilevel mediation analyses were conducted to determine whether change in psychosocial function (abilities, adjustment and participation subscales) explained change in functional independence (motor and cognitive subscales) from admission to discharge from services.
Results: Significant improvement in psychosocial abilities (−4.8, p < 0.001), adjustment (−2.9, p = 0.001) and participation (−2.5, p < 0.001) was seen from admission to discharge. Clinically and statistically significant improvements in motor (+11.8, p < 0.001) and cognitive (+9.5, p < 0.001) functional independence were also present. Mediation analyses indicated that change in psychosocial participation explained 81% of change in motor function, and 71% of change in cognitive function. Change in psychosocial adjustment explained smaller proportions of change in motor (26%) and cognitive (32%) function. Psychosocial abilities explained 60% of change in cognitive function, but did not predict change in motor function. Psychosocial participation fully mediated change in motor function. Findings indicate psychosocial function is critical for the improvement in functional independence through neurorehabilitation, with implications discussed.
328 Sex and gender differences in service use, clinical outcomes and mortality risk throughout post-acute community-based rehabilitation and disability support for acquired brain injury: a twenty-nine year perspective
Georgina Manna,b, Lakkhina Troeunga, Angelita Martinia,b
aBrightwater Care Group, Osbourne Park, Australia, bUniversity of Western Australia, Crawley, Australia
ABSTRACT
Background: Post-acute community-based rehabilitation is a critical dimension of rehabilitation and disability care for individuals with traumatic and non-traumatic acquired brain injury (ABI). However, despite known differences between men and women with ABI research has yet to examine gender and sex differences in service use patterns, clinical outcomes or mortality for those undergoing community-based post-acute supports. This study aims to identify any differing requirements between men and women with ABI.
Methods: Retrospective cohort study including all adults with ABI enrolled in post-acute neurorehabilitation and disability support services through a provider in Western Australia between 1991 and 2020, n = 1,011. Service use was evaluated through length of stay in post-acute care and the number of episodes of care for participants. Three key clinical outcomes were evaluated: Functional independence (UK Functional Independence Measure and Functional Assessment Measure), psychosocial functioning (Mayo-Portland Adaptability Inventory), and goal attainment (Goal Attainment Scale). Mortality rates were compared against Australian population reference data.
Results: Women were older on admission (p < 0.001) and displayed poorer functional independence (p = 0.018). At discharge, there were no significant differences between men and women in goal attainment (p = 0.576), functional independence (p = 0.736) or psychosocial function (p = 0.770). There were no gender differences in length of stay (p = 0.205), though Aboriginal and Torres Strait Islander women had significantly longer length of stay than men (+32.0 months, p < 0.001), and partnered women had shorter length of stay (−7.5, p < 0.001). Women also demonstrated significantly greater probability of requiring multiple episodes of care than men (+15%, p < 0.001), with some key differences in risk across diagnostic groups and chronicity. Men and women did not differ in their risk of death during care (p = 0.409).
Conclusions: Despite presenting with poorer functional independence, men and women appear to make equivalent gains throughout post-acute care, supporting the efficacy of community-based programs. While gender differences were not identified in length of stay, it appears that women may need additional supports to prevent multiple admissions and allow community reintegration. Implications will be discussed.
329 Blood-based dipstick test for damaged mitochondrial electron transport chain and severity of blast traumatic brain injury
Pushpa Sharmaa
aUniformed Services University, Bethesda, USA
ABSTRACT
Blast trauma is unique because of its complex mechanism of injury to the brain and other vital organs due to over pressure air and bleeding from internal organs. Severe loss of blood results in inadequate supply of oxygen and fuel to the cells for the generation of ATP from the mitochondria for the cell survival. Although clinical symptoms of metabolic disruption are evident soon after the injury, but actual damage mechanisms at the molecular, cellular and organ system level persists for days to years post injury. The ineffective treatments for TBI are mainly due to 1) lack of early blood-based biomarkers of metabolic failure and mitochondrial damage following brain injury, and 2) unsuccessful mitochondrial targeted treatment strategies.
Objectives: 1) develop blood based mitochondrial biomarkers of brain-injury severity, and 2) develop mitochondrial targeted therapeutic strategies.
Method: Pre-clinical rat model with blast exposure accompanied with or without HS and resuscitation was used. Blood collected at T0 (baseline), T60 (after injury), and T180 (end) was analyzed for blood mitochondrial enzymes by our published dipstick test.
Results: Compared with baseline values, a significant decreased activity of complex I, IV and Pyruvate Dehydrogenase Complex [PDH] was observed after blast and HS injury in all of the animal groups. The animals had also a statistically significant (p < 0.001) increased blood lactate concentration. The dysfunction of mitochondrial enzymes was inversely proportional to the blood lactate concentration (p < 0.05). Infusion of sodium pyruvate solution after the injury inhibited the complex I, IV and PDH aberrant activity near baseline value, and also corrected the hyperlactatemia at the end, and therefore attenuated the reactive oxygen species (ROS) production by mitochondria after the injury.
Conclusion: Serial monitoring and optimization of blood complex I, IV and PDH activity could aid in prognostication and potentially guide in using mitochondrial targeted therapies. Blood mitochondrial enzymatic assay might suggest global reduction-oxidation status.
330 Memory and traumatic brain injury: assessment and management practices of speech-language pathologists
Jade Mitchella, Natalie Covingtonb, Emily Morrowa, Michael de Riesthala, Melissa Duffa
aVanderbilt University, Nashville, USA, bUniversity of Minnesota, Minneapolis, USA
ABSTRACT
Memory impairments are the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with traumatic brain injury (TBI). Memory and learning are also critical for rehabilitation success and broader long-term outcomes. Speech-language pathologists (SLP) play a central role in memory management for individuals with TBI across the continuum of care. Yet, little is known about the current practice patterns of SLPs for post-TBI memory disorders. To address this gap, we created a 77-item survey to characterize the beliefs and practice patterns of SLPs serving adults with post-TBI memory impairments. We mailed surveys to 1800 SLPs in the United States and posted them on social media. Responses from 179 surveys were analyzed. Respondents had 14.7 years of experience, on average. Only 26.9% of respondents had taken a stand-alone course on TBI during their training. In comparison, most respondents (63.0%) received classroom training on TBI as part of an adult neurogenic communication disorders course covering TBI, stroke, and dementia. 10.1% of respondents reported receiving no classroom training in TBI. Only 64.7% reported that memory and memory management were covered in their coursework. In the assessment of memory, SLPs often work with an interdisciplinary team (69.4%). In memory treatment, however, nearly half of respondents (47.5%) reported that SLPs are the only discipline involved in treatment. Respondents reported the tools they used to assess different forms of memory (e.g., episodic, semantic, procedural, prospective, and working memory) and their intervention approaches. Respondents varied in their practice patterns in assessing and treating memory disorders, as well as in their use of evidence-based interventions. In assessment, some SLPs reported using standardized tests to measure aspects of memory that the tests were not developed to assess (e.g., Scales of Cognitive Ability for Traumatic Brain Injury to assess procedural memory). This reflects a lack of appropriate standardized assessments available to SLPs to measure particular forms of memory. In treatment, despite little evidence for the effectiveness of restorative memory interventions, 76.9% of respondents reported that clinical management of memory should include a combination of restorative and compensatory interventions, compared to 23.1% who reported that clinical management of memory should primarily include compensatory interventions. Respondents reported a range of barriers and opportunities to advance memory outcomes following TBI across clinical settings and provided suggestions of areas in which they would like to see more basic and clinical research. Taken together, these results provide new insights into the clinical management of memory impairment in TBI by SLPs and highlight opportunities to impact continuing education and standard of care that may, in turn, lead to improved memory outcomes for individuals with TBI.
331 Powerful poetry: exploring identity after brain injury through poetry, projects, and stakeholder engaged research
Audrey Nelsonb, Jerry Hoepnera
aUniversity of Wisconsin – Eau Claire, Eau Claire, USA, bBrain Injury Association of Wisconsin, Eau Claire, USA
ABSTRACT
Background: Cognitive communication changes following aphasia/brain injury disrupts one’s ability to express thoughts clearly. This can alter an individual’s sense of self or identity (Douglas, 2013). Reconstructing one’s sense of self and identity involves the development of a post-event identity (Lennon et al., 2014). Hoepner et al. (2022) found that project-based interventions contribute to reconstructing identity and a renewed sense of self. The intervention is designed to produce a self-identified, meaningful, concrete product or skill, which helps others. Contributors become experts in the process. Exploring self-narratives is another method for fostering renegotiation of identity (Ylvisaker et al., 2008). While there is limited systematic exploration of poetry following stroke and brain injury, poetry has been described as a modality for evoking a sense of self. During the pandemic, poetry was explored as a means of self-exploration, introspection, and means to build human connections (Acim, 2020).
Purpose: To examine the effects of a weekly poetry group and stakeholder engaged research project on sense of identity and purpose.
Methods:
Part 1: Seven poets with aphasia or brain injury, one care partner, three graduate student clinicians, and their clinical supervisor engaged in a 3-month examination of poems written by poets with aphasia/brain injury. Graduate student clinicians provided training on qualitative research methods to the seven poets and caregivers. Initial instruction was didactic but implicit training was used to teach the subtleties of this iterative, multistage qualitative analysis. Poets engaged in close reading of 39 poems, identifying specific meaningful impressions that resonated with shared experiences.
Part 2: Seven poets were interviewed regarding outcomes associated with the poetry workshops over the course of one year. Interviews were transcribed and analyzed through a multistage qualitative analysis. Author two (JH) and two student clinicians were involved in the iterative analyses.
Results:
Part 1: Stakeholder engaged research – Fifteen themes were identified, including both challenges and positive experiences associated with living with a brain injury/aphasia. Challenges included memory loss/forgetfulness, lack of motivation/feeling stuck, word finding difficulties, brokenness, loss of self, and loss of independence. Positive experiences included resilience/stubbornness/overcoming, warriors/fighters in a shared fight, poetry is chocolate/poetry is healing, successes, gratitude, acceptance, and relationships.
Part 2: Qualitative analyses of interviews with poets revealed the following themes: poetry is healing, didn’t know I was capable of writing poetry, poetry provides clarity, poetry refills my tank, poetry provides a sense of accomplishment, learning from one another and feeding off of one another, and poetry as a way to process recovery. Poets remarked that the poetry group was a safe place to express feelings. Ultimately, the participants integrated the identity of “poet” into their evolving identity/sense of self.
336 Use of olanzapine to treat agitation in post traumatic amnesia after TBI: a series of n-of-one cases
Adam McKaya,b,g, Ruby Phylandb,g, John Olverb,g, Mark Walterfangc,d,e, Malcolm Hopwoodc,f, Michael Ponsfordb, Jennie Ponsforda,g
aMonash University, Melbourne, Australia, bEpworth HealthCare, Melbourne, Australia, cThe University of Melbourne, Melbourne, Australia, dRoyal Melbourne Hospital, Melbourne, Australia, eFlorey Institute of Neuroscience and Mental Health, Melbourne, Australia, fAlbert Road Clinic Professorial Psychiatry Unit, Melbourne, Australia, gMonash Epworth Rehabilitation Research Center, Melbourne, Australia
ABSTRACT
Agitation is common during post-traumatic amnesia (PTA) following traumatic brain injury (TBI) and is associated with risk of harm to patients and caregivers. Antipsychotics are often used to manage agitation in early TBI recovery despite limited evidence to support their efficacy, safety and impact upon patient outcomes. This study describes the results of a double-blind, placebo-controlled randomized controlled trial investigating the efficacy of olanzapine for agitation management during PTA, analyzed as an n-of-1 series. Group differences in level of agitation, number of agitated days, agitation at discharge, duration and depth of PTA, length of hospitalization, cognitive outcome, adverse events and rescue medication use were also examined. Eleven agitated participants in PTA (mean age = 39.82 years, SD = 20.06; mean time post injury = 46.09 days, SD = 32.75) received oral olanzapine (n = 5) or placebo (n = 6) for the duration of PTA, beginning at a dose of 5 mg/day and titrated every three to four days to a maximum dose of 20 mg/day. All participants received recommended environmental management for agitation. A significant decrease in agitation with moderate to very large effect (Tau-U effect size = 0.37–0.86) was observed for three of five participants receiving olanzapine, while no significant reduction in agitation over the PTA period was observed for any participant receiving placebo. Effective olanzapine dose ranged from 5–20 mg. Response to treatment was characterized by lower level of agitation and response to treatment within 3 days. Participants receiving olanzapine demonstrated poorer orientation and memory during PTA with large effect size (olanzapine M = 9.32, SD = 0.69; placebo M = 10.68, SD = 0.30; p = 0.008, d = −2.26), and a trend toward longer PTA duration with large effect size (olanzapine M = 71.96 days, SD = 20.31; placebo M = 47.5 days, SD = 11.27; p = 0.065, d = 1.30). No further comparisons were statistically significant. These results suggest that olanzapine can be effective in reducing agitation during PTA, but not universally so, and may lead to increased patient confusion, possibly prolonging PTA. It is recommended that the potential benefits of olanzapine for agitation management are balanced with the possibility that the patient may never respond to the medication and may experience increased confusion, longer PTA and potentially poorer outcomes. Further high-quality research is required to support these findings.
337 Many hands: utilizing the ECHO model to identify and support interdisciplinary providers managing post-traumatic brain injury behavioral health problems
Jennifer Ericksona, Cherry Junna, Charles Bombardiera, Cara Towlea, Jesse Fanna
aUniversity Of Washington, Seattle, USA
ABSTRACT
Background: In the United States, traumatic brain injury (TBI) is a significant cause of disability. Chronic TBI-related disabilities can be partially attributable to behavioral factors such as post-traumatic stress disorder (PTSD), depression, anxiety, irritability, impulsivity, anger/aggression, substance misuse, and cognitive impairment. In addition, TBI increases the risk and complexity of a host of behavioral health (BH) conditions and complicates treatments that require patient self-management. Treating TBI’s complexities is challenging to manage as a solo provider. Despite a need for interdisciplinary interventions, few exist to support providers from multiple clinical backgrounds to learn from each other. Project ECHO (Extension for Community Healthcare Outcomes) fills this gap by connecting providers with specialists who provide structured didactics and case-based learning around community-submitted cases. It has successfully supported learners with varying medical backgrounds and treatment settings for multiple chronic conditions. We reviewed the literature around Project ECHO and TBI and identified potential learner stakeholders through community engagement. Finally, we describe the program development and initial evaluation of the first interdisciplinary TBI BH ECHO.
Methods: We reviewed the ECHO literature and past programs and found none addressed interdisciplinary education and post-traumatic brain injury behavioral health concerns. Our team of four interdisciplinary content experts in the areas of Rehabilitation Medicine, Rehabilitation Psychology, Neuropsychiatry, and Psychiatry met to generate a list of top high-yield topics. We sent a survey to community providers as part of a needs assessment to identify didactic needs and potential learners beyond physicians. Based on the results, we created a didactic schedule, started community recruitment, and launched the program in January 2022. Registration demographics, session attendance, and initial quarter evaluations have been collected.
Results: We convened three virtual meetings with the Washington State agencies and organizations that work to help support the treatment of TBI. Three organizations sent out our needs assessment to their contacts, and we received 14 individual needs assessments in return. Responses mainly were from mental health providers or social workers (80%), and a minority were physicians (7%). Fourteen lecture topics were selected based on expert consensus and our needs assessment results: TBI Identification; Persistent symptoms after concussion; Post-TBI Depression; Anxiety; PTSD; Substance Use Disorder; Bipolar/Psychosis; Sleep disturbance; Cognitive impairment; Chronic Traumatic Encephalopathy; Anger/irritability; Headache/Pain management; Apathy; & Fatigue. All of the respondents reported that these topics were important clinically. Since launching, we have had 256 participants register, 23% Medical Doctors/Doctors of Osteopathic Medicine/Doctor of Psychology, 7% Nurse Practitioners, 16% Social Workers, 14%Bachelors, and 40% others. Of those, 105 unique individuals have attended at least one session. We will also present the first quarter evaluation data for this program.
Conclusion: Project ECHO can offer a modality to support interdisciplinary education about post-traumatic behavioral health.
338 Are individuals with a traumatic brain injury more likely to experience challenges with video-conferencing? A cross sectional study
Sarah Chuaha, Diane Whitinga,b, Jerre Weaverc, Michelle Maitzd, Grahame Simpsona,e
aIngham Institute For Applied Medical Research, Liverpool, Australia, bSchool of Psychology, University of Wollongong, Wollongong, Australia, cMid Western Brain Injury Rehabilitation Service, Bathurst, Australia, dLiverpool Brain Injury Rehabilitation Unit, Liverpool, Australia, eJohn Walsh Center for Rehabilitation Research, University of Sydney, Australia
ABSTRACT
Background and Objective: Applications of digital technologies in healthcare are expanding, however the digital divide may prevent some groups from engaging in healthcare delivered online. The current study examined whether individuals with a traumatic brain injury (TBI) in a community setting were impacted by gaps in internet access, technology use and skill, and whether injury-related and demographic variables were associated with technology fluency, use, self-efficacy, and computer-related anxiety.
Method: Participants (N = 147; male = 81%) aged 18–65 years with a moderate to severe TBI were recruited from various sites across the Brain Injury Rehabilitation Program in New South Wales, Australia. Participants completed demographic and standardized measures assessing technology-related factors (Modified Computer Self-Efficacy Scale; Short Computer Anxiety Scale, Computer-e-mail-web Fluency Scale), along with project specific questionnaires assessing internet, device and videoconferencing (VC) use.
Results: On average, participants were 41.1 years of age, 22.9 months post-injury and had sustained a severe TBI (PTA 28.4 ± 27.13 days). Majority of the sample reported use of a smart phone (n = 146, 99.3%), with many using two or more internet-enabled devices (n = 102; 69.4%). The majority of those surveyed reported using the internet on a daily basis (81.9%) and had experience using VC since their injury (81.6%). Overall, technology fluency amongst the sample was high (M = 88.16; SD = 18.26), and injury-related variables such as time since injury and injury severity were not related to technology fluency, computer anxiety and computer self-efficacy. Age and lower education attainment were associated with lower levels of technology fluency and computer self-efficacy, while lower education attainment was also associated with greater computer anxiety.
Conclusion: Individuals with a TBI do not appear to experience unique challenges with current technologies, and as such, are well-placed to engage with internet-based healthcare such as video-consulting.
339 The magnitude and predictors of objectively measured physical activity during the first year after moderate to severe traumatic brain injury
Charles Bombardiera, Sujata Pradhana, Dmitry Esterovb, Simon Driverc, Kathleen Belld, Jason Barbera, Nancy Temkina
aRehabilitation Medicine, University Of Washington, Seattle, USA, bMayo Clinic, Rochester, USA, cBaylor Scott White Research Institute, Frisco, USA, dUT Southwestern, Dallas, USA
ABSTRACT
Introduction: Physical activity has been identified as a healthy behavior that might positively influence TBI recovery.1 This is based on voluminous research on the health benefits of engaging in at least 150 minutes per week of moderate to vigorous physical activity (MVPA) is beneficial for mood, sleep, fatigue, pain, and cognition.2 Multiple small studies suggest that people with TBI are deconditioned and physically inactive. Currently, we lack reliable and valid data on how physically active people are after TBI. Therefore, we conducted a longitudinal cohort study to investigate what proportion of people meet MVPA guidelines during the year following TBI and what factors predict greater MVPA.
Methods: Adult ambulatory patients at four TBI Model Systems inpatient rehabilitation centers in the U.S were recruited before discharge. Those who consented wore a triaxial accelerometer, the Actigraph GT3X, on their nondominant wrist continuously for 7 days after discharge from IPR and at 6 and 12 months post-TBI. Accelerometer data were scored in 60 second epochs using a cut score of at least 2020 counts per minute to define MVPA. We collected data on demographic and injury characteristics (age, sex, body mass index, education, time to follow commands, and neighborhood walkability score), self-reported secondary conditions (fatigue, depression, pain, sleep), cognitive functioning, as well as exercise intentions and self-efficacy to predict post-TBI MVPA. We used linear regression and multi-level modeling to predict minutes of MVPA at 12 months.
Results: 180 participants were recruited. The sample was 81% male, 49.9 years old on average, and 39% followed commands within one day of TBI. We obtained valid accelerometer data on 140, 105, and 93 participants at baseline, 6 months, and 12 months, respectively. At baseline, 6 and 12 months 66%, 72% and 77% of the sample demonstrated at least 150 minutes per week of MVPA. After controlling for all other variables, younger age, female sex, longer time to follow commands, and higher baseline minutes of MVPA all predicted greater minutes of MVPA at 12 months. Only 51% of those 62 or older had at least 150 minutes of MVPA per week versus 89–91% in the younger age groups. 83% of women versus 75% of men met MVPA guidelines.
Discussion: In this sample the vast majority of TBI survivors who participated in the study met MVPA guidelines by 12 months. Few variables predicted minutes of MVPA at 12 months. We observed a large decline in MVPA among persons older than 61 compared to those who are younger. Assuming physical activity is beneficial following TBI, older adults may be one at-risk group to target. It is possible that study participants were biased toward being physically active prior to injury. Future research should address this possibility.
340 Narrative discourse therapy for patients in post-traumatic amnesia: a feasibility study
Aashna Vazirania, Martin Checklina, Adam McKaya, Joanne Steelb
aEpworth Healthcare, Richmond, Australia, bUniversity of Newcastle, Callaghan, Australia
ABSTRACT
Background: Cognitive-communication deficits are a common sequelae of Traumatic Brain Injury (TBI) with 80–100% of people with TBI experiencing this type of communication impairment (MacDonald & Wiseman-Hakes, 2010). One of the main areas of difficulty which persists is the ability to construct sequenced narrative discourse (e.g. telling a story/anecdote, or retelling events). Studies have shown these impairments have significant long-term implications for effective communication and maintaining social relationships. Despite increasing evidence that intervention to treat these deficits should begin early after TBI, speech pathologists (SPs) typically provide minimal or no intervention in the TBI population during the post-traumatic amnesia (PTA) phase of an individual’s recovery. PTA is a state of confusion after someone experiences a TBI, and currently it is common practice that while patients are in PTA, direct therapy is limited due to the impression that therapeutic activities may lead to agitation. Recent studies, however, have demonstrated that patients in PTA can participate in some therapies such as physiotherapy (PT) and occupational therapy (OT) without adverse effects. While evidence to support OT and PT intervention while a person is in PTA exists, to what extent patients can participate in structured speech therapy is not yet known, as SP practices for patients in PTA are under-reported and require further investigation (Steel et al., 2013). Patients commonly wait many months until being cleared of PTA before commencing structured SP treatment, however, whether people in PTA can participate in SP intervention has not been investigated. AIM: This pilot feasibility study aimed to investigate whether patients in PTA tolerated and were able to participate in structured low-level narrative discourse therapy.
Methods: A treatment protocol was designed including two tasks targeting structured narrative story retell. 15 participants in PTA, recruited from a specialist brain injury rehabilitation inpatient ward, underwent up to 10 30-minute speech therapy sessions targeting production of narrative discourse from a set of 6-picture sequence stimuli and through supported retell of a related personal anecdote. Data was collected on pre-post narrative skills, agitation levels, participation, enjoyment, and session length.
Results: The results of this study are yet to be finalized, however, early analysis indicates that patients in PTA are able to tolerate participation in structured narrative discourse therapy without adverse outcomes.
Conclusion: It is feasible for SPs working with patients in PTA to provide structured therapy without increasing agitation. Further research with a larger sample size is warranted to investigate clinical effectiveness and efficacy of the therapy.
341 Continence and brain injury: care hours, cost and functional independence of neurorehabilitation and disability support
Angelita Martinia,b, Georgina Manna,b, Hayley Jacksona, Lakkhina Troeunga
aBrightwater Care Group, Inglewood, Australia, bThe University of Western Australia, Crawley, Australia
ABSTRACT
Background: Following acquired brain injury (ABI) it is common for individuals to require support across a number of psychosocial and functional domains. Continence management is a frequently required, costly and personal dimension of ABI that is often underreported and the costs associated are poorly understood. This pilot study aimed to 1) quantify toileting care hours and costs in a community-based ABI rehabilitation and disability setting, and 2) measure change in care needs, costs and functional independence following a continence intervention with assistive technologies.
Methods: This pilot study was a pragmatic pre-post intervention study of 14 adults with ABI and toileting disability accessing community based neurorehabilitation and disability support in Western Australia. Toileting costs and care hours, and functional independence was measured monthly from baseline to three month follow up. Basic and nursing care hours (Northwick Park Dependency Score), cost of care estimates (Northwick Park Care Needs Assessment), functional independence (Functional Independence Measure and Functional Assessment Measure) and cost of consumables was examined pre- and post-intervention with assistive technologies.
Results: Multilevel mixed effects modeling with bootstrapped estimation was conducted. Cost of consumables significantly declined (AU$69/week, p < 0.001), and functional independence significantly improved at the three-month post-intervention follow up (+23.5 points, p < 0.001). There was a non-significant reduction in care needs for toileting (4hrs/week, p = 0.060) and in the cost of toileting care (AU$633/week, p = 0.661), as well as a significant reduction in total care hours (8hrs/week, p = 0.025).
Conclusions: These findings indicate that toileting disability substantially impacts care hours and costs, and provides preliminary evidence that assistive technologies for continence management are beneficial in supporting people with ABI to increase independence, and reduce costs. Providing comprehensive continence assessment and management reduces reliance on staff for continence care and improves functional independence, a critical outcome for ABI rehabilitation.
342 Identifying priorities to inform co-design of an occupation-based virtual reality intervention for people with cognitive impairment after traumatic brain injury
Hannah Gulloa,b, Emmah Doiga,b, Giovanna Tornatorec, Janelle Griffind, Carla Caseye, Jennifer Fleminga, Freyr Pattersona, Trevor Russellb,f
aSchool of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia, bSurgical Treatment and Rehabilitation Service Education and Research Alliance, Metro North Health and The University of Queensland, Brisbane, Australia, cSurgical Treatment and Rehabilitation Service, Metro North Health, Brisbane, Australia, dPrincess Alexandra Hospital, Metro South Hospital and Health Service, Brisbane, Australia, eRoyal Brisbane and Women’s Hospital, Metro North Health, Brisbane, Australia, fRECOVER Injury Research Center, The University of Queensland, Brisbane, Australia
ABSTRACT
Background: Virtual reality (VR) technology is rapidly being developed as a modality for cognitive and occupation-based rehabilitation. Occupation is defined as “activities and tasks of everyday life, named, organised, and given value and meaning by individuals and a culture,” encompassing personal and instrumental activities of daily living, sleep and rest, leisure, play, social participation, work and education. VR technology enables users to be immersed in computer-generated environments allowing real-time interaction during simulated everyday activities. This approach has tremendous potential to enhance rehabilitation engagement, intensity, and early task practice in safe environments. Despite VR technology advancement, uptake within clinical practice is poor.
Aims: In this study, we explored perspectives of occupational therapists about (a) occupations important but challenging to address using occupation-based approaches and (b) the most relevant and useful therapeutic scenarios to simulate in VR to facilitate occupation-based rehabilitation.
Methods: A human-centered design approach was utilized with the initial stage involving four focus groups (1.5 hours each) with clinicians. Twenty-one occupational therapists (m = 12.89, 1–30 years practising) with specialized experience (m = 6.05, 0.5–26 years) providing cognitive rehabilitation to people with traumatic brain injury (TBI) in inpatient and/or outpatient rehabilitation settings, from three hospital sites, participated. The process explored their experiences and opinions about the use of VR with people with TBI based on collective clinical experience (50% with prior VR experience), to gain an understanding of requirements at various stages of care, potential context for use, and priorities for rehabilitation. Participants within each focus group generated a list of priorities as a group for design of future VR, and individual participants in the group rated each priority from 1 (not useful) to 10 (extremely useful). Responses across the groups were collated, noting commonalities, and overall usefulness ratings calculated to establish priorities for design.
Results: A list of potential VR-enabled occupation-based scenarios were generated. The top three areas rated as most relevant and useful for VR application development were: i) using public transport; ii) shopping; and iii) navigating in the community.
Conclusions: Clinicians identified key priority areas that could inform the development of occupation-based VR technology for use with people with cognitive impairment after TBI. The next stage will incorporate patient interviews to ensure their top ranked goals for rehabilitation may be triangulated with clinician views to identify the highest priority therapeutic scenarios for VR development. This will inform work involving the co-design of a VR application prototype for use in clinical practice.
343 Realizing community re-integration following acquired brain injury: process and outcomes
Mandy Nielsena,b, Kerrin Wattera,b, Areti Kennedya,b
aAcquired Brain Injury Transitional Rehabilitation Service, Princess Alexandra Hospital, Metro South Health, Brisbane, Australia, bThe Hopkins Center, Metro South Health & Griffith University, Brisbane, Australia
ABSTRACT
Community re-integration is a core rehabilitation goal following an acquired brain injury (ABI). A primary aim of the Acquired Brain Injury Transitional Rehabilitation Service (ABI-TRS) in Brisbane, Australia, is to facilitate early community re-integration outcomes for adults with ABI and their families during the transition from hospital to home. Results from a 5-year (2017–2021) evaluation of the ABI-TRS demonstrated improved community re-integration outcomes for clients with ABI over time and in comparison to a quasi-control group. This presentation will discuss these quantitative results with reference to key features of the service model, focusing on three community re-integration domains: home integration, social integration, and productive activity.
Method: Individuals with ABI completed the 12-week ABI-TRS community-based program, involving intensive, goal directed rehabilitation using an interdisciplinary, client-centered model. Self or clinician-rated questionnaires were completed at 0 (baseline), 3 and 12 months. Outcomes were compared to an historical quasi-control group (HIST). Specifically, this presentation reports MPAI-4 and SPRS outcomes. Data analysis involved linear mixed model analysis, random intercept models and post-hoc analysis. Data for the period January 2017 to March 2019 were included in the analysis (changes to service delivery commencing with the beginning of the COVID-19 pandemic meant that data post-March 2019 was excluded from analysis). Reported service model data was drawn from a process evaluation undertaken as part of the larger service evaluation.
Results: At baseline, ABI-TRS clients (n = 155) were more impaired across a range of items than HIST (n = 124) including functional abilities, independent living skills, home and community participation, adjustment to injury, interpersonal relationship status and occupational activity. A considerably shorter inpatient stay for ABI-TRS clients may have contributed to this. At 3 months post-hospital discharge, ABI-TRS clients had made significant clinical improvements, but HIST did not, in functional abilities, home and community participation, independent living skills, adjustment to injury and occupational activity. At 12 months post-hospital discharge (ABI-TRS data only), ABI-TRS clients continued to demonstrate statistically significant improvements in these areas. Service model features contributing to community re-integration included: intensive therapy services in the home and community; access to a range of individual and group-based interventions, as well as case management; a functional approach to therapy, with a focus on enabling participation in meaningful life roles, independence in the home and community, facilitating return to productive activities; and a family-centered approach which incorporates family and extended support network needs.
Conclusions: ABI-TRS clients made significant clinical improvements in relevant community re-integration domains which were maintained at 12-months post-hospital discharge. Key contributors from the service model were identified. It can be concluded that participation in ABI-TRS resulted in improved community re-integration outcomes for adults with ABI.
344 Supporting children, youth and young adults impacted by a family member with acquired brain injury
Angelita Martinia, Jeneva Ohanb, Robyn Betta
aBrightwater Care Group, Inglewood, Australia, bThe University of Western Australia, Crawley, Australia
ABSTRACT
Introduction: When acquired brain injury impacts individuals with dependent children, the lives of these young people are changed. This study partnered with families and professionals to understand the impact of parental injury and illness on dependent children from 0–24 years.
Method: 1) Resource evaluation; 2) Systematic literature review; 3) In-depth interviews with clients, parents, children and health professionals; 4) Qualitative observations; 5) Development of intervention/resources/materials; 6) Professional development seminars/workshops; 7) Survey of health professionals.
Results: Children needed to make adjustments to their lives and relationship with parents. Child feelings and emotions were significantly impacted, feeling alone and different, and experiencing an ongoing sense of loss. Challenges communicating about parental ABI, and interruptions to child development. Children need adults to understand their needs and to respond in a timely way, connection with the affected parent, social and professional support, and developmentally appropriate information. Gaps were found in age-appropriate and quality resources. This was mitigated by the publication of 4 children’s books, professional guides, and matrix of evaluated resources, websites and interventions. Resources were developed in consultation with families and professionals, and designed to readily be integrated into routine care.
Conclusion: Dependent children of parents with ABI are not a homogenous group and support must be available at many different points of family engagement with services. Multiple, age appropriate resources aimed at children, affected parents, co-parents and professionals were created, to help address the needs described.
345 Health system benefits of an integrated specialist acquired brain injury transitional rehabilitation service
Areti Kennedya,b, Kerrin Wattera,b, Mandy Nielsena,b
aABI TRS, Princess Alexandra Hospital, Metro South Health, Woolloongabba, Australia, bThe Hopkins Center, Metro South Health & Griffith University, Brisbane, Australia
ABSTRACT
Acquired brain injury (ABI) is a major health issue and a leading cause of disability worldwide1, highlighting a need to implement rehabilitation services that minimize the burden on health systems and associated costs, while at the same time meeting the needs of persons with ABI and their families. In 2016 a pilot ABI Transitional Rehabilitation Service (ABI-TRS) was established in Brisbane, Australia to address an identified need for specialized community-based transitional rehabilitation post-hospital discharge for adults with severe ABI. An embedded evaluation of the pilot investigated the impact of ABI-TRS for the broader health and community settings, including a detailed economic analysis. This presentation will discuss the evaluation outcomes, scrutinizing health system data, results from an externally commissioned economic analysis, and key service provider perspectives obtained via a nested qualitative study.
Method: Health system data was obtained from relevant hospital departments for financial years 2014/2015 to 2019/2020. Economic evaluation of ABI-TRS was conducted from commencement of clinical service in January 2017 to end March 2020. The qualitative study involved semi-structured interviews with key service providers within the hospital brain injury rehabilitation continuum and external rehabilitation services at two time points: after the first 12 months (December 2017-March 2018; n = 10) and after three years (February-June 2020; n = 12) of service delivery. Interview transcripts were analyzed thematically, guided by the Framework method.
Results: Health service improvements included: mean reduction of 8.8 days of inpatient brain injury rehabilitation unit (BIRU) stay between 2014–16 (pre-ABI-TRS) and 2017–19 (post-ABI-TRS); increased throughput and admission capacity in BIRU- additional 87 admissions during 2017–19; and capacity release in related outpatient post-discharge rehabilitation services. Key economic evaluation findings included: Benefit Cost Ration (BCR) of 2.42 from a societal perspective, gained through improved client productivity, health and wellbeing; reduced informal carer time costs; and financial benefits such as released capacity to the health system. The qualitative study identified three themes: ABI-TRS bolstering the continuum of brain injury rehabilitation services by addressing identified unmet need; providing a transitional rehabilitation “slow landing” post-hospital discharge, delivering necessary support for clients with ABI and their families; and equipping them for continuing rehabilitation, with ABI-TRS clients being described as “ahead of the game” by community rehabilitation service providers, i.e. in a better position to continue their rehabilitation than clients who had not been involved with ABI-TRS.
Conclusions: Evaluation of ABI-TRS indicated the program achieves health system benefits, providing value for money by improving patient health, wellbeing and productivity outcomes, and releasing capacity across the rehabilitation continuum. Service provider perspectives supported these results. The economic evaluation specifically concluded that ongoing investment in ABI-TRS would represent a sound investment in improving outcomes for people with ABI in Queensland.
347 Is the vocational intervention program effective in enhancing return to work after severe acquired brain injury? A controlled trial
Grahame Simpsona,b,c, Philippa McRaec,d, Thomas Gatesa,b,c, Maysaa Daherc,d, Deborah Johnstona,b, Ian Camerona,b
aFaculty of Medicine and Health, University Of Sydney, Sydney, Australia, bJohn Walsh Center for Rehabilitation Research, Kolling Institute, Sydney, Australia, cBrain Injury Rehabilitation Research Group, Ingham Institute for Applied Medical Research, Sydney, Australia, dBrain Injury Rehabilitation Directorate, Agency for Clinical Innovation, NSW Health, Sydney, Australia
ABSTRACT
Background: People of working age who sustain a severe acquired brain injury (sABI) have low return to work (RTW) rates, ranging from 16–40%. The Vocational Intervention Program (VIP) was developed to facilitate return to competitive employment after sABI, focusing on return to pre-injury employment or gaining new employment, by partnering local brain injury rehabilitation services with external vocational rehabilitation (VR) providers.
Objective: To conduct a 3-armed non-randomized controlled trial, evaluating the efficacy of the VIP partnership model (VIP) in facilitating a return to competitive employment, compared to an existing hospital-based brain injury VR service (H-VR) and treatment as usual (TAU) controls.
Methods: The trial was conducted among the 12 adult community rehabilitation sites of the New South Wales (NSW) Brain injury Rehabilitation Program (BIRP). Six sites delivered the VIP arm in partnership with three external VR providers selected for the trial. One site provided hospital-based vocational services (H-VR), and five sites TAU. Competitive employment status (Yes/No) and clinician ratings of disability (Dysexecutive Questionnaire; DEX) and participation (Sydney Psychosocial Reintegration Scale-2; SPRS-2) were collected pre- and post-intervention and at a 3-month follow-up. Multilevel modeling (with participants at level 2 and study time-point at level 1) was used to assess the impact of each arm on employment and clinical outcomes over the course of the study.
Results: A total of 149 people with sABI participated in the trial (VIP, n = 75; H-VR, n = 33; TAU, n = 40), of which 65 (60%) completed their VR intervention. The final model indicated that pre-intervention, the VIP (8%) and H-VR arms (6%) were less likely to be employed than TAU (38%) (p < 0.001). However, the VIP (61%) and H-VR arms (77%) demonstrated significantly higher rates of RTW post-intervention compared to TAU (56%) (p < 0.001). Clinicians rated all three groups as demonstrating lower levels of disability (mean DEX pre-post difference: VIP = −2.80 points; H-VR = −1.69; TAU = −3.84) and higher levels of participation (mean SPRS-2 pre-post difference: VIP = 3.28; H-VR = 5.74; TAU = 1.93) at post-intervention (ps< 0.01). Post-intervention differences in employment outcome and clinician ratings were largely stable at 3-month follow-up (ps> 0.31).
Conclusions: The VIP can be successfully delivered through partnerships between BIRP teams and VR providers. This provides a significant opportunity to build state-wide capability among the VR sector to more effectively facilitate RTW after sABI.
349 Is your client ready for brain injury rehabilitation via ehealth? A model of digital fluency using structural equation modeling
Diane Whitinga,b, Sarah Chuaha, Grahame Simpsona,c
aIngham Institute for Applied Medical Research, Liverpool, Australia, bSchool of Psychology, University of Wollongong, Wollongong, Australia, cJohn Walsh Center for Rehabilitation Research, University of Sydney, Sydney, Australia
ABSTRACT
Background and Objectives: Technology is an area of rapid change and its use in rehabilitation after brain injury has increased exponentially in recent years. There is limited understanding though about the factors which contribute to digital fluency in individuals with a traumatic brain injury (TBI); an important consideration for clinicians in the rapidly, evolving digital world. This study sought to identify the interactions between factors contributing to digital fluency in individuals with a TBI, to develop a model of digital fluency. This model would assist clinicians in identifying factors that may present challenges for delivering rehabilitation via eHealth.
Method: Participants (n = 147), aged 18–65 years, were community clients of the NSW Brain Injury program, Australia with a moderate to severe TBI. They completed questionnaires covering psychological factors (DASS-21; Short Computer Anxiety Scale-SCAS), access and usage of technology (Modified Computer Self Efficacy Scale) to examine how these factors interact and contribute to digital fluency (Computer-E-Mail-Web Fluency Scale), as well as demographic details (age, education, injury severity, digital devices used, time since injury).
Results: The sample comprised 81.0% (119/147) males with a mean age of 41.1 ± 14.7 years (range 18–65 years) on average 22.9 months since their injury. Overall, psychological distress mean score was 18.2 ± 15.2, with scores on the technology scales in the mid to high ranges indicating relatively high levels of digital fluency and computer self-efficacy. A test of the model demonstrated a good fit (χ2 = 6.65, p = 0.155; NFI = 0.981; IFI = 0.992; TLI = 0.958; CFI = 0.992; RMSEA = 0.067) and accounted for 62.0% of the variance in digital fluency. Higher Digital Fluency was indirectly predicted by increased years of education and lower general psychological distress with the relationship mediated by computer anxiety, the number of devices used in addition to a smart phone and overall computer self-efficacy. Computer anxiety was a key feature of the model with all other factors contributing to scores on this measure.
Conclusions: Clinicians can quickly review their client’s education levels and the number of devices currently used in addition to a smart phone, as a first measure to review eHealth readiness. Administration of the SCAS to determine computer anxiety levels will be useful to determine the level of support which may be required for the client before commencing rehabilitation via eHealth.
350 Virtual reality in cognitive rehabilitation – protocol for a randomized controlled trial
Truls Johansena,c, Martin Matrea,b, Marianne Løvstada,b, Anne Lundc, Anne Catrine Trægde Martinsena,c, Jennie Ponsforde,f, David Putrinof, Frank Beckera,b, Alexander Olsenh,i, Sveinung Tornåsa
aSunnaas Rehabilitation Hospital, Bjørnemyr, Norway, bUniversity of Oslo, Oslo, Norway, cOslo Metropolitan university, Oslo, Norway, dOslo University Hospital, Oslo, Norway, eMonash University, Clayton, Australia, fMonash-Epworth Rehabilitation Research Center, Richmond, Australia, gMount Sinai Hospital, New York, USA, hNorwegian University of Science and Technology, Trondheim, Norway, iTrondheim University Hospital, Trondheim, Norway
ABSTRACT
Objectives: Acquired brain injury (ABI) is a severe health issue that often leads to persisting somatic, cognitive, emotional and social impairments. Reduced processing speed and working memory dysfunction is common and can negatively affect activities of daily living, work attainment, and quality of life.
The ultimate goal of any cognitive rehabilitation effort is to improve real-life functioning. Rehabilitation efforts aiming to retrain attention and working memory have often consisted of computerized training programs. However, few studies have demonstrated effects that transfer beyond the trained tasks. There is a growing optimism regarding the potential usefulness of Virtual Reality (VR) in cognitive rehabilitation, as VR enables a contextualized training situation that resembles everyday life. Still, the research literature is sparse, and existing studies are characterized by considerable methodological weaknesses. There is also a great lack of knowledge about the acceptance and tolerability of VR as an intervention method for people with ABI, and no evidence-based clinical guidelines exist.
The overall aim of this study is to a) investigate the effectiveness of a commercial VR game in rehabilitation of sustained attention, processing speed and working memory, b) study transfer effects to everyday life and c) explore the tolerability and acceptability of VR in the ABI population.
Methods: One hundred participants (18–65 years), with a verified ABI, impairments of processing speed/attention, and/or working memory, and minimum 12 months post injury will be recruited from Sunnaas Rehabilitation Hospital. Participants with severe aphasia, apraxia, visual neglect, epilepsy and severe mental illness will be excluded.
The participants will be randomized into two groups; 1) an intervention group playing a commercial VR game taxing sustained attention, working memory and processing speed, 2) an active control group performing nonspecific cognitive tasks such as crossword puzzles or sudoku, in addition to receiving psychoeducation regarding compensatory strategies. The intervention period for both groups is five weeks. The VR-group will train at home for 30 minutes five days a week.
Each participant will be assessed at baseline, immediately after the intervention, and 16 weeks after baseline. Primary outcome is coefficient of variation from Connors Continuous performance test. Secondary outcomes include self-reported transfer effects into everyday functioning, working memory, and informant reported cognitive functioning. After the end of the intervention period, focus group interviews will be conducted to investigate acceptance and tolerability of the use of VR for 20 patients with ABI. A complete overview over study design and preliminary baseline data will be presented.
351 Comorbidity in stroke survivors in a medium-sized Swedish municipality
Peter Appelrosa, Marie Matérnea,b, Gustav Jarla,b,c, Mialinn Arvidsson Lindvalla,b
aUniversity Health Care Research Center,Faculty of Medicine and Health, Örebro University, Örebro, Sweden, bFaculty of Medicine and Health, Örebro University, Örebro, Sweden, cDepartment of Prosthetics and Orthotics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
ABSTRACT
Objectives: The purpose of this study was to evaluate the prevalence and impact of stroke-related comorbidity in a community-based sample of stroke survivors. With respect to the patients’ functional outcomes and general health, we wanted to find out which types of comorbidity were most important.
Materials and Methods: All stroke survivors (n = 330) living in a medium-sized Swedish municipality were included. To determine the presence of comorbidities patient records were reviewed. A selection of patient reported outcomes were used to assess subjective symptoms, functional outcomes, and general health. All patients were asked to answer a questionnaire, the Swedish Stroke Register (Riksstroke). Three questions from the questionnaire were used as additional measures of comorbidity. “Do you feel tired?,” “Do you have pain?” and “Do you feel depressed?” As outcome measures the patient reported measures from the Riksstroke questionnaire were used: * Do you still have problems after your stroke? * Have you been able to return to the life and activities you had before the stroke? * How is your mobility now? * Do you get help from someone when visiting the toilet? * Do you get help with dressing and undressing? * How do you assess your general health? Logistic regression models were used to investigate the association between comorbidities, residual symptoms, and subjective symptoms on the one hand, and functional outcomes and general health on the other hand.
Results: Hypertension (80%) was the most common cardiovascular risk factor. Ischemic heart disease was found in 18% and congestive heart failure in 10%. Of non-cardiovascular disorders, orthopedic diseases were commonest (30%). Psychiatric disorders and cognitive impairment were present in 11% and 12% respectively. Logistic regression analyses found that hemiparesis was associated with both poorer functional outcomes and lower general health. Additionally, orthopedic disorders, vertigo, cognitive impairment, nicotine use, chronic pulmonary disorders, and older age, were also associated with poorer functional outcomes. Psychiatric, orthopedic and neurological disorders were associated with poorer general health. The patient-reported outcome measure “feeling of tiredness” was a predictor of both outcomes, while “feeling depressed” and “having pain” were associated with poorer general health.
Conclusions: Many medical conditions, several of which have received little attention so far, are associated with poorer functional outcome and lower general health among stroke survivors. Future research into comorbidities relevant to function and general health in stroke patients could further focus on these disorders that hitherto have received little attention.
Key Words: Cerebrovascular disorders, Epidemiology, Sweden
352 Concussion knowledge and attitudes in elite rugby union in Ireland
Caithriona Yeomansa, Thomas M Comynsb,c,d, Ian C Kennyb,c,d, Mairead Listona
aIrish Rugby Football Union, Ballsbridge Dublin 4, Ireland, bDepartment of Physical Education and Sport Sciences. University of Limerick, Castletroy, Ireland, cHealth Research Institute. University of Limerick, Castletroy, Ireland, dSport and Human Performance Research Center. University of Limerick, Castletroy, Ireland
ABSTRACT
Sport-related concussions are often cited as one of the most common injuries in Rugby Union. Research suggests that women are at a higher risk of sustaining a concussion and younger players may experience greater symptom severity. Therefore, exploring ways to improve concussion prevention and management strategies in these cohorts should be a priority for sporting organizations.
Methods: Players from the national women’s (n = 30) and U20ʹs (n = 33) squads completed the Rosenbaum Concussion Knowledge and Attitudes questionnaire via Qualtrics. Players were then given an online concussion education module to complete prior to a tournament and subsequently repeated the questionnaire following the tournament to assess any differences in test scores. Informed consent was obtained prior to completion of the survey. Ethical approval was granted from the University of Limerick Research Ethics Committee.
Results: Players had high preeducation scores in concussion knowledge with mean test scores of 20.7 (± 1.6) and 19.9 (± 2.3) out of a maximum score of 25 in the women’s and U20ʹs squads respectively. Players also demonstrated safe attitudes toward concussion reporting and management preeducation, with mean test scores of 66.6 (± 5.7) and 61.9 (± 7.3) out of a maximum score of 75 in the women’s and U20ʹs squads respectively. Players with higher knowledge scores demonstrated safer attitudes overall. There were no statistically significant changes between preeducation and post-education scores for the women’s (knowledge = 20.5 ± 2, attitudes 64.7 ± 7.4) or U20ʹs (knowledge 17.4 ± 2.7, attitudes 65 ± 5.7) players. In the U20ʹs squad, players who had received both in-person and online education prior to this study demonstrated safer attitudes toward concussion reporting and management, than those who only received online education. It was also shown that rugby doctors and physiotherapists were the biggest influence on a player’s concussion awareness, with history of concussion and level of rugby playing experience also found to be influential on concussion knowledge and attitudes.
Discussion: These elite women’s and U20ʹs squads were highly knowledgeable prior to the education strategy and there were no significant differences in test scores following the education. History of concussion and level of playing experience may influence concussion awareness, highlighting the need for comprehensive concussion risk stratification and the importance of player history in the management of concussion. In-person learning is important and should be considered the main method of educating players, with online learning a useful adjunct. While higher concussion knowledge scores correlated to safer concussion attitudes this may not result in a behavior change regarding concussion reporting and management. However, education is still a vital component of prevention and future studies should investigate the relevance, complexity and amount of education provided to change behaviors and implement successful prevention strategies.
354 What can we learn from the experiences of children and youth with acquired brain injury and their parents about subacute physical rehabilitation? A qualitative study
Ingrid Rentinckb, Christiaan Gmelig Meylinga,b,c, Olaf Verschurena, Raoul Engelbertf,g,h, Jan Willem Gortera,d,e
aCenter of Excellence for Rehabilitation Medicine, Utrecht, The Netherlands, Utrecht, Netherlands, bDepartment of Pediatric Rehabilitation, De Hoogstraat Rehabilitation, Utrecht, The Netherlands, cHU University of Applied Sciences Utrecht, Institute of Human Movement Studies, Master Pediatric Physiotherapy, Utrecht, The Netherlands, dDepartment of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands, eDepartment of Pediatrics, CanChild Center for Childhood Disability Research, McMaster University, Hamilton, Canada, fDepartment of Rehabilitation, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdama, Amsterdam, The Netherlands, gFaculty of Health, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands, hDepartment of Pediatrics, Amsterdam UMC, Emma Children’s Hospital, University of Amsterdam, Amsterdam, The Netherlands
ABSTRACT
Background: Although physical rehabilitation programs after acquired brain injury (ABI) in children and adolescents have great potential to improve recovery, it is unclear how optimal physical rehabilitation should look like in subacute physical rehabilitation. The perspective of lived experiences with subacute rehabilitation in children and adolescents with ABI, and their parents, could provide insights in what they find important ingredients of physical rehabilitation interventions. These insights could inspire health professionals in pediatric neurorehabilitation and can inform the future development of a physical rehabilitation intervention program. The aim of this study is to explore the experiences and needs of children and adolescents with ABI and their parents on physical rehabilitation during the subacute phase.
Methods: Using a qualitative research design, 13 children and adolescents (< 18 years of age during their rehabilitation trajectory) and their parents participated in separate semi-structured interviews. Former patients of De Hoogstraat Rehabilitation (Utrecht, The Netherlands) were recruited to participate in his study if their rehabilitation trajectory was finished no more than five years ago. An inductive thematic analysis was carried out independently by two researchers.
Preliminary Results: Perceptions and experiences of children, adolescents and parents varied amongst the participants. Overall, six major themes emerged: 1) tailored care, 2) intensive physical rehabilitation, 3) optimizing parental engagement, 4) role of friends, 5) aftercare services and 6) stimulating environment.
Interpretation: Children, adolescents and parents expressed the need for a more intensive physical rehabilitation program, sufficiently tailored to the individual needs of the patient. Involvement of parents, siblings and friends is seen as beneficial with a potential role to increase physical activity during subacute rehabilitation. Hope and positivity were seen as essential factors to create a stimulating environment which is essential to optimize recovery after ABI.
355 Long-term health-related quality of life in elderly after mild traumatic brain injury: does the injury matter?
Sophie Coffenga, Amaal Eman Abdulleb, Harm van der Hornc, Myrthe de Koningc, Jacoba Spikmand, Joukje van der Naaltc
aDepartment of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands, bDepartment of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands, cDepartment of Neurology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands, dDepartment of Clinical Neuropsychology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
ABSTRACT
Introduction: The last decades the epidemiology of TBI has been changing with increasing numbers of elderly patients due to higher life expectancy. Elderly patients show higher mortality and slower rates of functional and cognitive recovery after sustaining a TBI compared to the younger population. However, studies on long-term outcome and quality of life after mTBI in elderly are scarce. Therefore, our aim was to determine the health related quality of life (HRQOL) of elderly patients with mild traumatic brain injury (mTBI) compared to younger patients with mTBI and to assess the early predictors of HRQOL for elderly patients.
Methods: This was a prospective observational cohort study in which we included patients with mTBI admitted to the Emergency Departments of three level one trauma centers in the Netherlands. Included patients were divided into two groups: Elderly (≥ 60 years, n = 169) and younger patients (< 60 years, n = 289). HRQOL as primary outcome 12 months post-injury was measured by World Health Organization Quality of Life scale abbreviated version. Information about trauma and general characteristics were recorded at the Emergency Department. Two weeks post-injury several posttraumatic symptoms were assessed with standardized questionnaires; posttraumatic complaints (Head Injury Symptom Checklist), anxiety and depression (Hospital Anxiety and Depression Scale) and posttraumatic stress (Impact of Event Scale). Coping was evaluated with the Utrecht Coping List. The Glasgow Outcome Scale Extended (GOSE) measured recovery after 12 months.
Results: One year post-injury 80% (n = 128) of the elderly patients rated their HRQOL as “good” or “very good.” Incomplete recovery (GOSE < 8) was found in 43% (n = 69) elderly patients, but 66% (n = 46) of these elderly patients with incomplete recovery reported a good HRQOL. No difference was found in HRQOL compared to patients aged <60 years (78% (n = 218), p = 0.73). Posttraumatic complaints, posttraumatic stress, depression and anxiety did not differ between age groups (p > 0.05). Elderly patients less frequently used a passive coping style (19% vs. 28%, p = 0.03). Multivariable analyses revealed that only depression-related complaints (OR 1.14, 95% CI 1.01–1.29, p = 0.03) were a significant predictor of decreased HRQOL in elderly patients.
Conclusion: One year after mTBI the majority of the elderly patients rated their HRQOL as good, similar to the younger patients, despite the fact that a substantial part of the elderly patients showed incomplete recovery according to the GOSE. This phenomenon is called the disability paradox. Depression emerged as a significant predictor for lower HRQOL and can be identified as an early target for treatment aiming to improve wellbeing on the long-term.
356 The use of hypnotic suggestion in rehabilitation of working memory after acquired brain injury. study protocol of a randomized controlled trial
Line Sophie Eidea, C.Psych Per-Ola Rikea, C.Psych Silje Endresen Remeb, C.Psych Jonas K Lindeløvc, C.Med Hildegun Snekkevika, C.Med Stephan Rossnerd, C.Psych Gunnar Rosend, C.Psych Marianne Løvstada,b
aSunnaas Rehabilitation Hospital, Nesodden, Norway, bUniversity of Oslo (UIO), Oslo, Norway, cAalborg University (AAU), Aalborg, Denmark, dNorwegian Association of Clinical Evidense-based Hypnosis (NFKEH), Oslo, Norway
ABSTRACT
Objectives: Establishment of effective, efficient, and evidence-based interventions in rehabilitation of working memory (WM) deficits after acquired brain injury (ABI) is sorely needed. Despite robust evidence for the efficiency of clinical hypnosis in a wide range of clinical conditions, and improved understanding of mechanisms underlying it ́s effects, the potential of clinical hypnosis in cognitive rehabilitation is virtually unexplored. A recent study has shown large effects of hypnotic suggestion on WM capacity following ABI. This randomized controlled trial (RCT) aims to evaluate and explore replicability of these findings. The study will also explore the underlying mechanisms of change.
Methods: Ninety patients will be recruited from Sunnaas Rehabilitation Hospital. Inclusion criteria are non-progressive ABI, minimum 12 months post- injury, ongoing WM deficits, and age between 18 and 67 years. Patients will be randomized to either a) an intervention group receiving four weekly 60 min. sessions with induction and hypnosis, b) an active control group receiving four weekly 60 min. sessions of induction and mindfulness, or c) a passive control group without intervention. The targeted procedure consists of suggestions about enhancing WM functions through the instantiation of preinjury WM ability in the present using age regression and visualizations of brain plasticity. The non- targeted suggestions contain no explicit mentioning of ABI or WM-related abilities. Each participant will be assessed at baseline, immediately after intervention and six months after baseline. The primary outcome is the WM Index from WAIS-IV and self- and informant reported WM Subscale from BRIEF-A, a questionnaire exploring executive functioning in everyday life. Secondary outcomes include self-reported memory self-efficacy, emotional distress, quality of life and community integration. A process evaluation will be carried out to evaluate treatment experience.
Discussion: Rehabilitation of impaired WM after ABI has hitherto yielded limited clinical effects, and clinical trials of new interventions are thus warranted. Long-standing empirical evidence demonstrates that hypnosis is an effective therapeutic technique in a wide range of conditions and recent exploratory research has suggested efficacy of hypnosis in improving WM in patients with ABI. However, these extraordinary findings need replication in studies applying scientifically rigorous designs. If successful, our ambition is to provide recommendations and materials to implement hypnotic suggestion as an adjunct treatment following ABI. Study findings may inform future studies exploring the use of clinical hypnosis in other areas of rehabilitation, such as mild TBI, and in other neurological conditions where WM deficit is prominent.
The study protocol, parts of the treatment manual and preliminary data will be presented. The scientific literature on clinical hypnosis in relation to cognitive rehabilitation is provided, hypothesized treatment mechanisms explored, and implications of findings highlighted.
357 Dizziness-related disability one year after a mild to moderate traumatic brain injury – a follow-up study
Ingerid Kleffelgårda, Nada Andelica,b, Helene Lundgaard Søberga,c
aDept. of Physical Medicine and Rehabilitation, Oslo University Hospital, 0424 Oslo, Norway, bCenter for Habilitation and Rehabiliation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, 0316 Oslo, Norway, cDepartment of Rehabilitation Science and Health Technology, Faculty of Helath Sciences, Oslo Metropolitatn University., 0130 Oslo, Norway
ABSTRACT
Background: Problems with dizziness and balance can persist for a year or longer after mild to moderate traumatic brain injury (TBI) and may result in considerable disability and poor health-related quality of life (HRQoL).
Objectives: To describe persistent dizziness and balance problems and HRQoL one year after mild to moderate TBI, and to explore associations between patients characteristics and post-injury functioning at baseline and dizziness-related disability at one year post injury.
Methods: A one-year follow-up study of patients originally included in a randomized controlled trial. The participants were evaluated as one cohort in this study because there were no between-group differences in dizziness-related disability at one year post-injury. A total of 64 patients, aged 16–60 years, who had a dizziness score ≥ 2 (i.e., mild, moderate, and severe problems) on the Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and/or had a positive Romberg’s test were included. Data collection was conducted at baseline 3.5 (SD 2.1) months after the injury, and 12.1 (SD1.6) months after the injury. The primary outcome measure was the Dizziness Handicap Inventory (DHI) one year post-injury. Independent variables were demographic and injury-related variables, and measures of post-injury functioning at baseline (RPQ; Vertigo symptom scale-short form, VSS-sf; Hospital anxiety and depression scale, HADS; Balance error scoring system, BESS and High-level mobility assessment tool, HiMAT). Independent variables that qualified for further analyses (significant association with DHI at one year in a simple linear regression analyses) were entered into a multivariate linear regression model. The Quality of Life after Brain Injury, QOLBRI, was used to assess HRQoL.
Results: Mean age at inclusion was 39.4 (SD 13.0); 45 (70.3%) were women. Patients with dizziness and balance problems improved significantly from moderate to mild dizziness-related disability after one year; changes on the DHI from baseline to one year were 42.8 (SD 16.6) to 26.0 (SD 18.8), mean change: −16.8 (CI −11.9, −21.6) p < 0.001. The model that best explained dizziness related disability after one year consisted of more pre-injury comorbidity, more neck-pain, more post-concussion symptoms (RPQ) more dizziness (VSS-sf) and reduced balance (HiMAT) Adjusted R2 = 0.370. F = 6.52 p < 0.001. In addition, we found a significant improvement in HRQoL from baseline to one year on the QOLIBRI from impaired 56.7 (SD 17.3) to non-impaired 66.1 (SD 17.2), mean change: 9.4 (CI 4.6, −14.2) p < 0.001.
Conclusion: There was a significant improvement in dizziness-related disability and HRQoL from 3.5 months to 12 months after the injury. Factors associated with dizziness-related disability one year post injury such as pre-injury comorbidity and neck pain, symptom burden, dizziness and balance problems at baseline should be addressed in the rehabilitation programs at the early stages of injury. Clinical Trials Registry (# NCT01695577).
358 Perceived communication abilities after moderate to severe traumatic diffuse axonal injury
Marjaana Raukola-Lindbloma,b, Linda Ljungqvistc, Timo Kurkid,e, Heikki Hämäläinena, Olli Tenovuof
aDepartment of Psychology and Speech-Language Pathology,University of Turku, Turku, Finland, bSote Academy, University of Turku, Turku, Finland, cCity of Turku, Welfare division, Psychosocial services, Turku, Finland, dDepartment of Radiology, University of Turku, Turku, Finland, eTerveystalo Medical Center, Turku, Finland, fDepartment of Neurology, University of Turku, Turku, Finland
ABSTRACT
Background: Cognitive-communication disorders after traumatic brain injury (TBI) are common and persistent. Cognitive-communication deficit refers to any aspect of communication affected by disruption of cognition. These deficits can arise from multiple causes, including memory, executive functions, linguistic functions, emotional control, and self-regulation problems. Cognitive-communication difficulties are usually not recognized in a general screening of cognitive-linguistic abilities. Still, they can produce long-term difficulties in social participation, reintegration into the workplace, and family circumstances. When detecting cognitive-communication disorders, it is essential to also include the subjective perceptions of TBI patients. Their perceptions of communication difficulties are particularly valuable when identifying clinical rehabilitation needs and planning meaningful, effective rehabilitation goals.
Objectives: The study aims to determine how working-age individuals with traumatic diffuse axonal injury (DAI) perceive their communication abilities before and after TBI.
Methods: La Trobe Communication Questionnaire (Douglas, O’Flaherty, & Snow, 2000) was applied to 41 individuals aged 19–53 (M = 36, SD 9) with moderate to severe DAI. All participants (13 men, and 28 women) were in the chronic stage. La Trobe Communication Questionnaire evaluated the self-rated communication abilities before and after TBI. These two self-ratings were compared with Wilcoxon signed-rank test.
Results and Conclusion: The results indicate that individuals with DAI perceived significant negative changes in their communication abilities after TBI. Results show that individuals with traumatic DAI experience multiple difficulties in everyday communication. We conclude that even in pure DAI, cognitive-communication deficits are common. It seems essential to include self-rating methods in a comprehensive cognitive-communication assessment to fully understand the needs for rehabilitation and support. The updated results and conclusions will be presented at the conference.
360 Mental fatigue and distractibility after a mild traumatic brain injury
Birgitta Johanssona
aInstitute Of Neuroscience And Physiology, Gothenburg, Sweden
ABSTRACT
Most Traumatic Brain Injuries are mild (mTBI) yet many people suffer from long-term mental fatigue and cognitive impairment. Distractibility is common in ordinary life, but is seldom included in standard neuropsychological assessment.
Aim: This study was designed to investigate the effect distraction may induce in top-down and bottom-up attention among people who suffer from mental fatigue after mTBI.
Method: Thirty mTBI patients suffering from mental fatigue and 30 healthy controls performed a computerized test, including Simple Reaction Time, Choice Reaction Time and Attentional Capture tasks with a salient distractor.
Results: A slower processing speed was found in all subtests for the mTBI group and was particularly noticeable for the decision-making task. The distraction stimulus reduced processing speed for both groups, while the mTBI group made more omissions when a distractor emerged, indicating increased distractibility. However, no effect in top-down and bottom-up attention was found. Response time in the presence of a distractor was a predictor for mental fatigue, while depression and anxiety were not.
Conclusion: It is suggested that people suffering from mental fatigue after mTBI are slower at processing information, and this is more pronounced when a cognitive demand is added to the task. Distractibility was indicated with more omissions during distraction, but a distinction between top-down and bottom-up systems was not found. As distraction is common in daily living, especially when considering the ability to successfully return to work when suffering from mental fatigue after a brain injury, it is important to develop cognitive tests that are adapted to the real world. The results also show the importance to understand fatigue, depression and anxiety as separate entities. Currently the underlying origin of mental fatigue and distractibility after an mTBI are not well known and future studies are needed.
361 Assessment of work ability when suffering from mental fatigue, a screening method
Birgitta Johanssona
aInstitute Of Neuroscience And Physiology, Gothenburg, Sweden
ABSTRACT
Long-lasting mental fatigue is a pathological state with an extreme mental energy deficit and reduced ability to regain this energy in response to activity. This results in reduced quality of life and impaired ability to maintain employment or educational status. There are currently no methods for assessing work ability for patients suffering from mental fatigue.
Aim: In this study, work ability in relation to mental fatigue as a screening method was evaluated, using the Work Ability Index (WAI) and Mental Fatigue Scale (MFS) in patient groups commonly suffering from mental fatigue.
Method: A randomized selection of 200 participants/group who have had contact with their health center during the past 5 years for acquired brain injury (TBI or stroke), hypothyroidism or burn-out syndrome were contacted by mail. The intention was to capture those who had recovered and those who were still suffering from mental. Participants reported actual percentage of full-time working hours and the questionnaires answered were WAI and MFS.
Results: The results showed a significant correlation between WAI and MFS (r = – 0.754) and status in the workplace (WAI r = 0.722, MFS r = – 0.443) for all groups. The WAI and MFS were significant predictors for status in the workplace (p < 0.001) and explained 53% of the variance. Neither diagnostic group, age or gender, turned out to be significant predictors.
Conclusion: This study showed that mental fatigue is related to work ability and work status in the workplace. This screening method can help health care professionals to identify people who are mentally fatigued with a reduced ability to work or return to work after illness, and who are in need of in-depth investigation. It is important to initiate treatment early with the aim of promoting a sustainable working life and general well-being of the individual.
362 Mindfulness for alleviating fatigue after an acquired brain injury
Birgitta Johanssona
aInstitute Of Neuroscience And Physiology, Gothenburg, Sweden
ABSTRACT
In chronic phase after an acquired brain injury, many report problems with mental fatigue and having a reduced ability to participate in ordinary living with work and social activities. Many also suffer from isolation, frustration and emotional problems. To adapt and manage life in new ways is a process and takes time. In this perspective, mindfulness can be an alternative and can be a treatment option in health care. Mindfulness is meditations but also much more, simply how to live life in an insightful and balanced way. The program Mindfulness Stress Reduction (MBSR) is promising for many illnesses, including acquired brain injury. MBSR includes meditation, group discussions with the intention to increase the awareness of healthy responses. We have evaluated the MBSR program with; in-person group meetings, live online group meetings, individually guided Internet MBSR with pre-recordings and a qualitative evaluation of in-person group meetings. The participants included have all suffered from long-term mental fatigue after and acquired brain injury. We have shown reduced mental fatigue, depression and anxiety symptoms, and improved cognitive function. Participants from the face-to-face meetings and live on Internet reported sharing experiences with the others as highly appreciated, with gain of awareness of the condition. This in turn implied new perspectives on how to relate to mental fatigue. MBSR delivered live on Internet gives people the opportunity to get access to the program when face-to-face meetings are not possible. The MBSR program for those suffering from mental fatigue need modifications, with a slower pace, less talk and more repetitions. The Individually guided Internet MBSR with pre-recordings have no face-to-face meetings, which is a drawback. On the other hand, it can be adapted to individual needs, when and how the program is performed. They can do the program in a slower pace, can repeat the prerecorded parts, and extend the program over more weeks if they need.
Conclusion: Mindfulness with the MBSR program have the potential to alleviate fatigue after an acquired brain injury, reduce emotional responses and improve cognitive function. MBSR can improve well-being and help people managing life with more of ease and with acceptance, but in new ways.
363 Description and analysis of neurocognitive health among individuals experiencing homelessness in Paris, France
Gaëtan Chevreaua, Claire Vallat-Azouvia, Marie-Carmen Castilloa
aUniversité Paris 8 Vincennes Saint-denis, Saint-denis, France
ABSTRACT
Introduction: Homelessness is a major issue in our societies. Despite the social nature of this phenomena, homelessness is highly associated with health factors including somatic disorders (Henwood et al., 2018) and psychiatric conditions (Laporte et al., 2018). Regarding the numerous risk factors for Brain Injuries (BI) experienced by homeless people, a growing literature has emerged to understand better their neurocognitive health. Studies have confirmed that people experiencing homelessness are at higher risk to suffer from stroke (Zhou et al., 2019) or Traumatic Brain Injuries (Stubbs et al., 2020). Other publications have described cognitive impairments among this population (for a literature review, see Depp et al., 2015). To our knowledge, such issues have never been studied in France, while homelessness is very different from a country to another. As an example, many homeless men in the USA are veterans, while a vast majority of homeless people in France are migrants. These differences may impact risk factors met among the homeless population and more generally their neurocognitive profiles.
Objectives: We conducted a research project between 2018 and 2022, aimed to assess the neurocognitive health of a sample of homeless Parisians. A pilot study (Chevreau et al., 2021) helped us to identify most common risk factors and methodological levers to take into account for a larger-scale study.
Methods: The main study is currently conducted with homeless subjects living in different Parisian shelters, with the objective to achieve a sample size of 50. Subjects are first interviewed on their sociodemographic characteristics and are asked to fulfill questionnaires to evaluate signs of substance abuse, neurocognitive complaints, depression, anxiety, Post-Traumatic Stress Disorder. This first part is followed by a full neuropsychological assessment, composed of an evaluation of working memory, episodic memory, executive functioning, visuospatial functions, speech, social cognition.
Results: the main results of this study will be presented. We will focus on characteristics of subjects with history of TBIs and analyze specificities of this subgroup in terms of sociodemographic and cognitive profiles.
Conclusion: We will discuss implications of such results in the social care of individual experiencing homelessness and in the prevention of social follow-up of patient with TBI.
364 The utility of blood biomarker S100B as a measure of brain injury in professional rugby players; a longitudinal study
Aine Kellya, James Halea, Noreen Boylea, Karl Denvirb, Garreth Farrellb, John Ryanb, Brendan O’Connellb, Joice Cunninghama, Oisin Joycea, Jason Wysea, Fiona Wilsona
aTrinity College Dublin, Dublin 2, Ireland, bLeinster Rugby, Dublin 14, Ireland
ABSTRACT
Background: Athletes playing Rugby have an increased incidence of sports-related-concussion (SRC) with a meta-analysis reporting 4.73 concussions per 1000 player match hours. The heterogeneity and diagnostic complexity of SRC means there is no single diagnostic test available pitch-side. The role of neurologically selective blood markers has garnered interest as a method to identify and assess damage to neuronal and glial cells. If such biomarkers could be identified, their utilization as a point of care test for diagnosis, and recovery monitoring would be invaluable. Their specificity and reliability would need to be assured both as a short and long-term measure in measuring brain health. One such biomarker, is S100B, a calcium binding protein. S100B has two sources of production and release, intracerebrally by astrocytes and extra-cerebrally by adipose tissue, muscle and skin. S100B link to brain injury is well established. Our previous studies showed that in rowers, a small increase in circulating S100B occurs following intense exercise, but a larger effect is seen in rugby players post-match, without concussions, verses their baseline preseason values. Bouvier et al., showed that following concussion, a minimum increase of 20% of baseline values identified concussion with 100% sensitivity and 81% specificity. The effect of a full season’s play is not yet established. Studies that follow players across multiple seasons capturing concussions as they appear during the course of normal play have also not been examined. Any potential biomarker would need to have resilience and reproducibility across multiple seasons of play. In addition, the cumulative degenerative effects of repeated concussions need to tracked, with the long term levels monitored.
Objectives: Our aim was to observe the effect of multiple seasons play and SRC, utilizing S100B a potential blood serum biomarker, in male professional rugby players.
Methods: Over a 3-season period, blood samples were collected from 18 players in pre-season, post-season and following SRC (within 2–24 h). A control group of elite rowers (n = 14) were assessed pre- and post-training.
Results: S100B levels did not change significantly over multiple seasons, and timepoints were comparable across all three seasons. When samples were grouped by only pre-season, post season and SRC irrespective of season, S100B did change significantly from pre-season values to SRC (P = 0.002), and from SRC to post season values (P = 0.013). To account for the highly individualistic nature of S100B levels, a fold-change comparison was made for each player from pre-season to SRC. This showed a 2.42 change in versus only a 1.12 for pre-season post-season in non-concussed individuals.
Conclusion: Individual and repeated seasons’ play does not affect circulating S110B levels in professional male rugby players. SRC does cause a temporary elevation, which returns to normal by season’s end and does not directly affect future seasons’ values.
365 Transcutaneous vagal nerve stimulation to treat disorders of consciousness: a double-blind randomized controlled trial
Marie Vitelloa,b, Marie-Michèle Briandc, Olivia Gosseriesa,b, Jitka Annena,b, Didier Ledouxb,d, Riëm El Tahrye, Steven Laureysa,b, Aurore Thibauta,b
aComa Science Group, GIGA-Consciousness, University of Liege, Liège, Belgium, bCentre du Cerveau2, University Hospital of Liège, Liège, Belgium, cResearch Center of the Hôpital du Sacré-Coeur de Montréal, Montreal, Canada, dIntensive Care Unit, University Hospital of Liège, Liège, Belgium, eCatholic University of Louvain, Ottignies-Louvain-la-Neuve, Belgium
ABSTRACT
Patients with disorders of consciousness (DoC) are a challenging population prone to misdiagnosis and lacking effective treatment options. At present, there are no evidence-based guidelines regarding the treatment of patients with DoC. However, among neuromodulation techniques, transcutaneous auricular vagal nerve stimulation (taVNS) may act trough a bottom-up manner to modulate thalamo-cortical connectivity and promote patients’ recovery. In this clinical trial, we aim to test the clinical and neurophysiological effects of taVNS in patients with DoC and determine the phenotype of clinical responders. We will conduct the first prospective parallel randomized placebo-controlled double-blind trial in DoC patients with taVNS. Forty-eight patients in the early period following brain injury will randomly receive 5 days of either active bilateral vagal stimulation (45 min duration with 30s alternative episodes of active/rest periods; 3 mA; 200–300 μs current width, 25 Hz.) or sham stimulation. Behavioral (i.e., Coma Recovery Scale-Revised) and neurophysiological (i.e., high density electroencephalography) measures will be collected at baseline and at the end of the treatment. Analyses will seek for changes in the behavioral total scores and the EEG metrics (i.e., alpha band power spectrum, functional connectivity) at the individual and group levels. Preliminary results will be presented at the conference. Improvements in the CRS-R total score and in the subsequent index score, as well as the appearance of new signs of consciousness will be our primary outcome. Such patients will be considered as responders. As secondary outcomes, we expect that the clinical changes in responders will be correlated with the EEG metrics. These results will contribute to define the role of taVNS for the treatment of these challenging conditions, identify the neural correlates of its action and pave the way to targeted therapeutic strategy.
366 Establishment of a public and patient involvement group for acquired brain injury in an irish context: an acquired brain injury ireland and irish critical care-clinical trials network collaboration (in progress)
Ellen Conlona, Alistair Nicholb, Leanne Haysb, Katie Ainscoughb, Dylan Keeganc
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland, bIrish Critical Care Clinical Trials Network, UCD Clinical Research Center, Ireland, cUCD Clinical Research Center, Ireland
ABSTRACT
Background: 19,000 new acquired brain injuries (ABIs) occur in Ireland each year. Due to the impact an ABI can have on individuals and their families, it is essential to conduct high-quality research to improve outcomes and quality of life for survivors. Since its establishment in 2000, Acquired Brain Injury Ireland (ABI Ireland) has prided itself on being a person-centered neurorehabilitation and advocacy organization. As well as developing individualized neurorehabilitation plans for its service users, ABI Ireland have placed importance on sharing the experiences of ABI survivors in Ireland. ABI Ireland’s research and policy department are committed to promoting ABI research and building collaborations with researchers in Irish universities to facilitate evidence building opportunities. In accordance with this, Patient and Public Involvement (PPI) has become a priority for us. It was agreed that the idea that PPI allows research to be “carried out ‘with’ or ‘by’ members of the public,” not just ‘to,’ ‘about’ or ‘for’ them” is very much in line with ABI Ireland’s values, and thus building a PPI group was initiated. Since 2015, the Irish Critical Care-Clinical Trials Network (ICC-CTN) have conducted high quality multicentre clinical trials in Ireland including an ABI program of activities. As well as undertaking large ABI clinical trials, the ICC-CTN have a significant program of PPI activities and experience in establishing such groups. With seed funding from the PPI Ignite Network at University College Dublin, a collaboration between ABI Ireland and the ICC-CTN was established.
Aim: To establish the first ABI PPI group in Ireland that includes ABI survivors with diverse ABI causes and neurorehabilitation experiences, who can inform ABI research and assist a neurorehabilitation organization prioritize future research endeavors.
Methods: The first phase of this project targets two geographical regions in Ireland, the greater Dublin area in the East, and the counties of Clare and Limerick in the South-West of the island. Under the guidance of clinical neuropsychologists at ABI Ireland, potential members (goal: n = 16) of the PPI group are being identified. Individuals will be provided with relevant training and agree on terms of reference through their preferred methods of communication, and via online sessions. Following training, in person meetings will be initiated in respective regions. While research staff from the Acquired Brain Injury Ireland and the ICC-CTN collaboration will facilitate training and meetings, it is hoped that PPI group members will equally make suggestions and decisions on discussion topics. Following phase one, it is hoped that the membership of the PPI group can be expanded to other regions, allowing further embedding of PPI in ABI Ireland and Irish ABI researchers’ activities. The ICC-CTN will bring knowledge from their experience building PPI groups to guide the steps necessary to the project’s success.
367 Cervical range of motion and pericranial tenderness score in post-concussion syndrome
Laura Westh Stenbroa, Amalie Hellemosea, Jørgen Feldbæk Nielsena, Peter Preben Eggertsena
aHammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Aarhus, Denmark
ABSTRACT
Background: Post-concussion syndrome (PCS) is a prevalent condition following mild traumatic brain injury (mTBI), with an estimated incidence of 15% after a first-time concussion. PCS is a clinical diagnosis based on persistent heterogenic and nonspecific symptoms associated with reduced health-related quality of life, prolonged disability, and reduced working capacity. Due to similarities in the clinical presentations, it is considered whether PCS shares etiology with Chronic Whiplash-Associated Disorder (WAD). Previous studies have found reduced cervical range of motion (CROM) and increased pericranial total tenderness score (pTTS) common in WAD. However, research on changes in CROM and pTTS in PCS is sparse. If significant changes in CROM and pTTS can be detected in patients with PCS, it would support the hypothesis that PCS and WAD share etiology and that patients with WAD and PCS might consequently benefit from similar treatment strategies.
Aim: We aim to examine the assessed CROM in patients with PCS compared to reference values. Secondly, we aim to examine the association between the level of PCS symptoms (measured by the Rivermead Post-Concussion Symptom Questionnaire (RPQ)), CROM, and pTTS in patients with PCS.
Methods: A cross-sectional study will be conducted in a hospital setting using data from a separate randomized trial examining the effect of a novel intervention, “Get going after concussion” (GAIN), in patients with PCS. Patients in the GAIN cohort (19–30 years) had PCS, defined as an RPQ-score ≥ 20 2–6 months after mTBI. CROM was measured using a gravity-referenced inclinometer system. The pTTS was assessed by categorizing the visual and verbal reaction provoked by manual palpation of eight pericranial trigger points.
To define reference values of pTTS and CROM, a systematic literature search will be performed using the PubMed database.
Results: A total of 108 patients were included from the study cohort of the GAIN study.
The primary outcome will be the mean difference between measured values of CROM in patients with PCS and reference values. Secondary outcomes will be 1) mean difference in pTTS in patients with PCS and reference values and 2) the association between scores of RPQ and measured values of CROM and pTTS in patients with PCS. Results of the analyses will be presented at the conference.
Discussion: This study will provide important information regarding CROM and pTTS in patients with PCS in a hospital setting.
If changes in CROM and pTTS are found in patients with PCS, it would accentuate the benefits of a shared treatment strategy for PCS and WAD. Further, it would support the hypothesis of a shared etiology between PCS and WAD, which would be highly relevant to developing evidence-based treatment of post-traumatic sequelae in patients with PCS.
368 Effects of non-confrontational feedback during cognitive rehabilitation on self-awareness of deficits after acquired brain injury
Anneke Terneusena,b, Ieke Winkensa,b, Math Leindersc, Rudolf Pondsd, Caroline Van Heugtena,b,e
aDepartment of Neuropsychology & Psychopharmacology, Maastricht University, Maastricht, The Netherlands, bLimburg Brain Injury Center, Maastricht University, The Netherlands, cDepartment of Brain Injury Rehabilitation, Adelante Zorggroep, Hoensbroek, The Netherlands, dDepartment of Medical Psychology, Amsterdam University Medical Center, location VUmc, Amsterdam, The Netherlands, eMHeNS School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
ABSTRACT
People who receive cognitive rehabilitation after acquired brain injury often lack awareness of their deficits. They may not understand the changes caused by the brain injury and the impact these have on them and others. Impaired self-awareness may limit motivation for and participation in rehabilitation therapy and may negatively affect rehabilitation outcomes. Adequate treatment of impaired self-awareness of deficits is necessary but literature on evidence-based treatments is limited. The main aim of this study is to investigate the effects of a new intervention during cognitive rehabilitation on self-awareness of deficits. Secondary aims are usability of the intervention, and the effects of the intervention on motivation for therapy, participation during therapy, quality of life, social participation, and mood. In a multi-center randomized controlled trial adults with acquired brain injury were assigned to care as usual (N = 25) or a new intervention consisting of psycho-education and cognitive tasks combined with non-confrontational feedback (N = 39). Effects were investigated three and six weeks, and three, six, nine, and twelve months after the start of cognitive rehabilitation. These included effects on self-awareness of deficits (Self-Regulation Skills Interview; Patient Competency Rating Scale), motivation for therapy scored by the patient (Motivation for Traumatic Brain Injury Rehabilitation Questionnaire) and by the therapist (10-point Visual Analogue Scale), participation during therapy (Pittsburgh Rehabilitation Participation Scale), quality of life (Stroke Specific Quality of Life Scale – 12), social participation (Utrecht Scale for Evaluation of Rehabilitation – Participation), and mood (Hospital Anxiety and Depression Scale – Depression). Preliminary analyses based on mixed ANOVA indicate that on the short-term there is no significant difference between treatment groups on self-awareness and participation. Self-awareness did improve over time regardless of treatment group (F(2, 62) = 5.30, p < 0.05). Self-reported motivation improved only for the people in the care as usual group (F(2, 92) = 4.41, p < 0.05). Multilevel analyses on the long-term effects at three, six, nine and twelve months after the start of the cognitive rehabilitation data are currently being conducted and will be presented.
369 Sub-symptom threshold aerobic exercise for patients with exercise intolerance after mild traumatic brain injury: a feasibility study
Lars-Johan Valaasa,b,c, Helene L. Søberga,d, Mari S. Rasmussena,d, Nada Hadzic-Andelica,b,c, Ingerid Kleffelgårda
aDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, bInstitute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, cCenter for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, dDepartment of Rehabilitation Science and Health Technology, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
ABSTRACT
Background: After mild traumatic brain injury (mTBI) there is an increased risk of exercise intolerance. Sub-symptom threshold aerobic exercise (SSTAE), exercise without post-concussion symptom (PCS) exacerbation, has shown promising results in reducing symptom burden and improving exercise tolerance in young athletes in the sub-acute phase post-injury. However, the effects of SSTAE in an adult mTBI population are largely unknown.
Objective: To evaluate the feasibility of SSTAE according to the Buffalo Concussion Treadmill Test (BCTT) protocol in an adult population in preparation for a randomized controlled trial.
Methods: Non-randomized, pre-post design with baseline assessment and follow-up after 12 weeks of SSTAE. Patients aged 18–60 years with mTBI, treated at a specialized TBI outpatient clinic, with persistent PCS 3–24 months post-injury were included. Outcome measures: Rivermead Post-Concussion Symptom Questionnaire (RPQ, primary outcome), BCTT (secondary outcome), Quality of life after TBI (QOLIBRI), Patient Specific Functional Scale (PSFS), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder (GAD-7), Dizziness Handicap Inventory (DHI), Headache Impact Test (HIT-6), Fatigue Severity Scale (FSS), International Physical Activity Questionnaire (IPAQ). We developed predefined success criteria based on literature and previous clinical trials at our department: Recruitment process (˃ 50% consent rate), retention rates (< 20% drop-out), outcome assessments (appropriateness and < 10% missing data), adherence to the intervention (attendance ˃ 67%, adherence ˃ 3 weekly exercise sessions, exercise diary ˃ 67%).
Results: Nine patients, mean (SD) age 38.8 (11.2) years, 89% females, with exercise intolerance were included. Consent rate and retention rate was acceptable at 72% and 18% respectively. Completion time of the questionnaires was acceptable (92% < 40 minutes) and < 0.4% missing items. The QOLIBRI was replaced with the shorter QOLIBRI-OA, to reduce questionnaire completion time, and DHI was removed as few experienced dizziness. Adherence to the intervention was satisfactory with ˃ 90% attendance rate of follow-ups, 75% performed the prescribed home exercises, 88% maintained the exercise diary. An adherence to the intervention questionnaire was added, the Problematic Experience of Therapy Scale (PETS). On the BCTT we changed stop criteria from voluntary exhaustion to 90% of estimated max heart rate or ≥ 18 BorgRPE 6–20, to reduce PCS exacerbation after testing and cardiovascular risk. Mean (SD) RPQ decreased from 25.9 (8.7) at baseline to 17.1 (6.7) at follow-up (t: 3.46, p < 0.01). Exercise tolerance increased from mean (SD) 83% (13) of estimated HRmax to 91% (7) (t: 2.39, p < 0.05). No serious adverse events were reported during the study.
Conclusion: The SSTAE intervention and study procedure were feasible with minor adjustments. The patients reported reduced symptom burden and were able to exercise at a higher intensity after 12-weeks SSTAE. We are currently enrolling patients to our RCT. Clinicaltrial.gov: NCT05086419.
370 Riding my bike, reading my watch, cooking and tying my shoes: can CO-OP (cognitive orientation to daily occupational performance) help children with executive functions deficits after acquired brain injury reach their goals? A single case experimental study using a randomized multiple baseline design across participants and across goals
Helene Lebraulta, Rose Martinib, Agata Krasny-Pacinic, Rumen Manolovc, Mathilde Chevignarda,b,c
aRehabilitation department for children with acquired neurological injury, Saint Maurice Hospitals, Saint-Maurice, France, bSorbonne Université, Laboratoire d’Imagerie Biomédicale, LIB, Paris, France, cSorbonne Université, GRC 24, Handicap Moteur et Cognitif et Réadaptation (HaMCRe), Paris, France
ABSTRACT
Children with Acquired Brain Injury (ABI) often suffer from Executive Functions (EF) deficits that affect participation in everyday activities. Cognitive Orientation to Daily Occupational Performance (CO-OP) is an individualized approach that teaches cognitive strategies necessary to support successful performance. There have been few studies on the effectiveness of CO-OP with this population.
Aim: to evaluate the improvement in occupational performance (i.e., the achievement of the goals the children have chosen to improve), following rehabilitation using CO-OP with children with EF deficits following ABI.
Method: a systematic replicated Single Case Experimental Study using a randomized multiple baseline design across participants and across goals was used. Twelve children/teenagers (8–16y) with EF deficits following ABI, divided into 3 clusters of 4 patients, were included (i.e., one original study and two replications). They received 14 individual sessions of CO-OP intervention (2 sessions per week during 7 weeks). Each child using the Canadian Occupational Performance Measure (COPM) set four goals. Three goals were trained during CO-OP sessions while the fourth was a control goal. Goal achievement was measured using repeated measures (3 to 6 times during baseline, at each session and at 2, 4, 6 months post-intervention) of Goal Attainment Scales (GAS), who was your primary outcome. We used four different COPM ratings for each identified goal: (1) Child-rated goal performance scale; (2) Child-rated satisfaction scale; (3) Parent-rated performance satisfaction scale; (4) Parent-rated satisfaction scale. COPM ratings were obtained at pre-intervention, immediately post-intervention, and at 2, 4, and 6-months post-intervention.
Results: at the end of the intervention, the children had reached the expected level (level 0 of the GAS or higher) for almost all trained goals. Visual and quantitative statistical analyses (two types of modified Brinley Plots were used to show individual effects of CO-OP across participant and across their goals i.e., inter and intra-subject effect replication; A Nonoverlap of All Pairs (NAP) for each goal of a single participant to obtain an effect size for each goal separately; A combined NAP for all children; A multilevel analysis for the whole study to obtain an intervention effect size and significance at the “group” participants level) confirm these results. The improved GAS scores were generally maintained during the follow-up phase (± one level). A significant change in performance and satisfaction (child and parents’ COPM) was achieved for almost all trained goals at post-intervention and it was maintained at follow-up.
Interpretation: These results seem to confirm that teaching the child to explore problem solving, and to use the CO-OP strategies, is a useful approach to improve their occupational performance. The generally positive results of this study add to those of previous research and support the value of using the CO-OP with this severely impaired population.
371 Ready to care- informal caregiving for people with prolonged disorders of consciousness in Ireland
Alison McCanna, Mark Delargyb, Tadhg Stapletonc
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland, bMedical Director, National Rehabilitation Hospital, Dun Laoghaire, Ireland, cDiscipline of Occupational Therapy, School of Medicine, Dublin, Ireland
ABSTRACT
Introduction: This study examined the prevalence of informal caregiving for people with prolonged disorders of consciousness (PDOC) among an Irish cohort. It highlighted the range of care tasks undertaken and the preparation caregivers received to adopt this unexpected role. This study set out to examine the nature of this informal caregiver role, the typical care tasks provided and the impact of the role on the caregiver in the Irish context.
Method: Participants were adult, unpaid caregivers. A postal survey examining aspects of their caregiving roles and routines was completed.
Results: Questionnaires were returned by 20 caregivers (12 (60%) Female); 3 (15%) were providing home-based care and 17 (85%) were providing supplementary caregiving to a relative who was resident in a nursing home. The majority of caregivers were either parents (11 [55%]) or spouses (8 [40%]). All home-based caregivers assisted with activities of daily living (ADL), daily therapy related care, and sensory stimulation activity. Caregivers providing supplementary care to a relative resident in nursing homes and the majority reported visiting their relative daily or several times per week. Visits involved frequently providing ADL and therapy related care during their visits, and a vast majority (82–94%) provided sensory stimulation activities during every visit. Self-rated health of caregiver showed statistically significant decline since assuming the caregiving role (P = 0.001). Overall, preparation to undertake this life-changing role was viewed positively. Participants were asked their views of how well the rehabilitation facility assisted with this. Seventeen of 20 provided data. Twelve (n = 12, 70%) reported receiving some or a lot of preparation from the rehabilitation facility. Two of the three home caregivers received no preparation. Tutoring in nursing care tasks such as managing PEG feeding, observation of skin integrity, using a hoist, positioning, application of splints and managing to take their relative on outings made up core caregiving training. Despite the training, fewer than half of the 13 residential caregivers who responded (n = 5, 38%) reported feeling ‘very confident with caregiving.’ All three of the home caregivers reported feeling ‘very confident’ with this role, despite reporting poor levels of training.
Conclusion: Informal caregiving occurs daily for numerous hours, for individuals with PDOC. It ranges from assisting with ADL’s to bringing the care recipient on outings. The role is enduring, time demanding, varied and has a negative impact on the health of the caregiver. Inconsistencies emerged relating to preparation received to undertake this life-changing role. An opportunity has been highlighted for rehabilitation facilities to address this to ensure that informal caregivers receive appropriate advice, practical skills training, and follow-up review regarding how their role may evolve over time so as to support their own wellbeing.
372 Exercise-induced symptom exacerbation in moderate to extremely severe traumatic brain injury
Sara Gallowa,b, John Olvera, Jennifer McGinleyb, Gavin Williamsa,b
aEpworth Healthcare, Richmond, Australia, bThe University of Melbourne, Parkville, Australia
ABSTRACT
Question: What is the incidence of exercise-induced symptom exacerbation with cardiorespiratory fitness (CRF) and high-level mobility (HLM) assessment in early sub-acute, moderate to extremely severe traumatic brain injury (TBI)?
Design: Observational study
Methods: Consecutive admissions to the inpatient unit of Epworth Rehabilitation, Victoria, Australia were screened for recruitment. Patients were eligible if they had sustained a moderate to extremely severe TBI ≤ 3 months prior, were out of post-traumatic amnesia and met physical and cognitive criteria to be able to complete testing. Consenting participants undertook exercise testing involving HLM or CRF. Symptom exacerbation was measured using a 22-item symptom scale which was completed at baseline and post exercise test.
Results: Five hundred and twenty-six consecutive admissions were screened for recruitment between August 2017 and August 2021. Of these, 212 met inclusion criteria and 150 consented and completed testing. One hundred and seventeen participants were male and 33 female with a mean age of 37 years. Eighty-three participants undertook CRF testing alone, 12 HLM testing alone and 57 both CRF and HLM testing. Two participants experienced exercise-induced symptom exacerbation, one during HLM testing and one during CRF testing. One adverse event, a fall, occurred during a HLM testing session.
Conclusion: High-level mobility and CRF assessment in the early sub-acute phase of recovery following moderate to extremely severe TBI appears to be safe, with low rates of symptom exacerbation and adverse events found in this study. The low rate of symptom exacerbation identified in this study supports an individualized approach to early commencement of CRF and HLM assessment following moderate to extremely severe TBI.
373 Getting back to work, training and education after brain injury. the experience of a vocational rehabilitation service in an Irish context: step ahead plus with acquired brain injury Ireland
Laura Reillya, Anne Connollya, Ellen Conlona, Emer Duffya, Ciara Nolana, Deirdre O’Neilla, Lily Nguyena
aAcquired Brain Injury Ireland, Dublin, Ireland
ABSTRACT
Background: In Ireland 19,000 new Acquired Brain Injuries (ABI) occur each year. ABI survivors often face challenges returning to work or education due to difficulties such as memory, fatigue, and mobility. Step Ahead Plus is an occupational therapy led Vocational Assessment (VA) and Vocational Rehabilitation (VR) service for adults with ABIs delivered by Acquired Brain Injury Ireland since 2019. It is a national service, accepting both clinician and self-referrals. Service is delivered in a hybrid model consisting of in person assessment, followed by telehealth rehabilitation. In this investigation we examined the profile and outcomes of clients referred to the service between April 2021 to June 2022.
Methods: Analysis was carried out using retrospective data collected from clients referred between April 2021 and June 2022. The outcome measurement used to assess the effectiveness of the Step Ahead Pus service was the Mayo-Portland Adaptability Inventory-4 (MPAI-4). MPAI-4 scores were collected from clients during VA and at discharge post VR, and analyzed using paired sample tests with SPSS software.
Results: Between April 2021 and June 2022, 231 ABI survivors were referred to the Step Ahead Plus service. Of these, 60 declined service. 76 received VA as per service prioritization guidelines. 42 of those went on receive VR and a subsequent discharge assessment. Characteristics of the 42 clients were as follows: 60% male, 40% female; mean age 41 years (range: 19–67 years). 71% of ABIs were non-traumatic in nature. Most common causes of ABI were stroke (n = 21), road traffic accident (n = 5), and fall (n = 5). Upon VA, 12% of clients were actively employed, 42% were on sick leave, and 36% were unemployed. Following VR, 74% of clients were in employment (full-time (n = 24); part-time (n = 7)). Additionally, 2 clients entered an education or training program. MPAI-4 subscale T-score changes were as follows: Ability 0.585 (95% CI [−0.106, 1.277], p = 0.95), Adjustment 3.119 (95% CI [1.027, 5.211], p = 0.004), and Participation 7.69 (95% CI [4.775, 10.606], p < 0.001). The mean time between initial and discharge assessment was 28 weeks.
Conclusion: VR had a positive impact on clients’ ability to return to work or education. Our referral data demonstrates a high demand for service, however, Ireland currently has limited VR programmes on offer to this cohort. Despite variances in characteristics and ABI causes, outcomes following VR were positive for most clients. We note the MPAI-4 may not be a sensitive measure for the effectiveness of this service. While statistically significant differences were seen in adjustment and participation subscales, staff leading this service are in the process of identifying a more applicable outcome measurement. Future investigations aim to access differences in outcome depending on variables such as sex, time within service, and ABI cause.
374 BrainACT: acceptance and commitment therapy for people with acquired brain injury
Caroline Van Heugtena, Johanne Rauwenhoffa, Frenk Peetersa, Yvonne Bolb
aMaastricht University, Maastricht, Netherlands, bZuyderland medical center, Sittard, Netherlands
ABSTRACT
Patients with acquired brain injury (ABI) often experience symptoms of anxiety and depression. Until now, evidence-based treatment is scarce. This study aimed to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) for patients with ABI. To evaluate the effects and feasibility of BrainACT for people with ABI, we conducted a series of non-concurrent multiple baseline design studies across four cases and a multicenter Randomized Controlled Trial (RCT) comparing ACT with a control treatment (education and relaxation). Both effectiveness and feasibility were evaluated.
The four cases were randomly assigned to a baseline period, followed bytreatment and then follow-up phases. Anxiety and depressive symptoms were repeatedly measured. During six measurement moments over a year, participants filled in questionnaires measuring anxiety, depression, stress, participation, quality of life, and ACT-related processes. Randomization tests and NAP scores were used to calculate the level of change across phases. Clinically significant change was defined with the Reliable Change Index.
Three out of four participants showed medium to large decreases in anxiety and depressive symptoms (NAP = 0.85 till 0.99). Furthermore, participants showed improvements regarding stress, cognitive fusion, and quality of life. There were no improvements regarding psychological flexibility, value-driven behavior, or social participation.
A process evaluation of the BrainACT treatment was conducted alongside an RCT investigating its effectiveness. The attendance and compliance rates, engagement with the protocol, satisfaction of participants and therapists, and perceived barriers and facilitators for delivery in clinical practice were investigated using therapy logs and semi-structured interviews with participants and therapists.
Twenty-seven participants and 11 therapists participated in the feasibility study. We found high attendance rates and both participants and therapists were satisfied with the intervention. Moreover, participants were motivated and engaged in homework exercises. The compliance rate, however, was relatively low. After finishing the treatment, patients reported to still apply the ACT skills obtained during the BrainACT intervention. Key strengths are the structure provided with the Bus of Life metaphor, the experiential nature of the intervention, and the materials and homework exercises.
In the RCT, 72 patients were included and randomly assigned to BrainACT or control treatment. We are currently finalizing the follow up measurements. Final results of the RCT will be presented during the conference.
This study shows that BrainACT is possibly an effective and feasible treatment option for people experiencing ABI-related anxiety and depression symptoms. The results of our RCT should confirm these findings.
375 Dissociating the impact of alexithymia and impaired self-awareness on emotional profiles after traumatic brain injury
Suvi Dockreea,b, Cathal Ffrenchb, Jodie O’Haraa, Paul Carrolla, Paul Dockreec, Brian McGuireb
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland, bUniversity of Galway, Galway, Ireland, cTrinity College Dublin, Dublin, Ireland
ABSTRACT
Alexithymia is a deficit in emotional processing, characterized by difficulty identifying and describing one’s own feelings. It is highly prevalent in traumatic brain injury (TBI) and typically associated with frontal lobe damage. Sometimes referred to as emotional unawareness, it was of interest whether organic alexithymia following TBI was related to, or distinct from impaired self-awareness (ISA), and whether the two predicted distinct emotional profiles. TBI patients (N = 40) completed self-report questionnaires of alexithymia, emotional distress, aggression, and frontal system behaviors. For comparison, significant other ratings were obtained from the Frontal Systems Behavior Scale to identify discrepancies from self-ratings. Two-tailed bivariate correlations revealed that higher alexithymic tendencies were associated with fewer expressions of ISA. Directional correlations demonstrated that alexithymia was associated with higher expressions of depression, anxiety, aggression, and general emotional distress, whereas no such relationships were found for ISA. Alexithymia remained significantly correlated with general emotional distress and aggression even after controlling for the effects of ISA via partial correlations. Exploratory simple mediations demonstrated that frontal system behaviors (disinhibition and dysexecutive function) mediated the relationship between alexithymia and aggression, and dysexecutive function mediated the effects between alexithymia and emotional distress. In conclusion, the findings posit that alexithymia is a deficit in its own right, distinct from a more general impaired self-awareness, but is not immune to the effects of ISA. It is more accurately conceptualized as a deficit in emotional processing than a deficit in self-awareness. Indeed, a degree of self-awareness may be a pre-requisite for the ability to recognize alexithymic tendencies. Negative psychological effects of post-TBI alexithymia are compounded by poorer executive function and impulse disinhibition and call for the development of TBI-specific alexithymia screening tools and large-scale intervention studies. Alexithymia interventions may be best delivered in conjunction with neuropsychological rehabilitation for frontal system behavior changes.
376 Golden slumber: the importance of sleep in stroke rehabilitation
Sarah Caseya, Patricia Conroya, Claire Converya, Paul Carrolla,b,c
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland, bSt. Vincent’s University Hospital, Dublin, Ireland, cRoyal Hospital Donnybrook, Dublin, Ireland
ABSTRACT
Introduction: As a leading cause of disability, it is important to continue to focus on the management of modifiable stroke risk factors. Conventional wisdom tells us that getting a good night of sleep is integral to our health and wellbeing, and attention has turned to sleep as a modifiable risk factor in primary and secondary stroke prevention. Indeed, in recent years there has been a surge of research examining the role of sleep in maintaining good physical, cognitive, and psychological health. Studies have shown that optimal windows of sleep are important for reducing the risk of stroke, and for secondary stroke prevention. Furthermore, studies have shown that sleep plays an important role in stroke rehabilitation: sleep optimizes neuroplasticity and recovery, with sleep duration and efficiency correlating with cognitive outcome in both acute and chronic stages of stroke recovery; sleep optimizes memory, executive, emotional, interpersonal, and adaptive functioning following stroke; and sleep enables good engagement in rehabilitation and everyday activities.
Methods: Our team aims to develop a multi-modal, interdisciplinary intervention with the aim of empowering patients to optimize sleep, including learning effective skills and strategies for self-management, both on the unit and in their own living environments. In addition to literature review, this includes reviewing elements drawn from treatment-as-usual (such as medication review, environmental management, sleep hygiene, sleep education, physiotherapy consultation, and psychological therapy), the development of interdisciplinary processes and referral pathways, developing NRH-relevant educational materials, and developing an interdisciplinary education workshop.
Results: Initial engagement and feedback in the development phase has been positive. There is improved staff awareness of potential sleep difficulties and available interdisciplinary interventions. Sleep goals are integrated into person-centered rehabilitation plans. Patients report improved understanding of sleep for health, function and wellbeing and enjoy peer support in education. We are currently working to streamline our educational workshop and hone a coherent assessment and intervention protocol.
Conclusion: In order to maximize neurorehabilitation outcome, it is important to optimize sleep for stroke patients. Based on our initial interdisciplinary work, we aim to develop a protocol that will ensure a person-centered plan for sleep optimization, which we would hope to assess in a full pilot.
377 Neuropsychomotor treatment pre/post nerve growth factor in a pediatric patient with severe traumatic brain injury
Sara Caporroa, Susanna Stacciolia, Sarah Bomparda, Enrico Castellia, Antonio Chiarettib,c
aBambino Gesú Children’s Hospital, Via della Torre di Palidoro, Rome, Italia, bInstitute of Pediatrics, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy, cFondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
ABSTRACT
Background: Nerve Growth Factor (NGF) is a neurotrophin that promotes neural recovery and plasticity after brain injury. Its function is demonstrated by pre-clinical and clinical studies where NGF supports brain cells neural growth, differentiation and their survival. Very few studies examined the use of NGF in pediatric patients with compromised cerebral function after traumatic, ischemic or infective brain injury (Chiaretti et al. 2020; Chiaretti et al.2017).
Methods: This study describes changing of the rehabilitation approach after experimental NGF therapy in a 5 years-old child with severe traumatic brain injury outcome. Response to treatment was assessed with qualitative neuropsychomotor valuations, daily caregivers observations and standardized tests for residual motor skills monitoring (GMFM) and state of consciousness changing in everyday life (DRS).
Results: At the beginning of neuropsychomotor treatment it has been impossible to perform most of the GMFM’s items; after experimental NGF inoculation and a one-year rehabilitation treatment the patient demonstrated increased motor and consciousness skills in GMFM and DRS tests.
Conclusions: According to our experience, even if neurobiological outcomes can demonstrate NGF therapy combined to Neuropsychomotor Rehabilitation effects in a more objective way, clinical and neurofunctional changes can modify quality of Life of caregivers and of patients with disorders of consciousness after a severe traumatic brain injury.
378 Long-term follow-up of critically ill traumatic brain injury patients: from intensive care parameters to patient and caregiver reported outcome
Fleur Domensino, Jeanette Tasa,c, Babette Donnersc, Joyce Kooymana, Iwan van der Horsta, Roel Haerena,e, Marcel Ariësa,c, Caroline van Heugtena,b,f
aSchool for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands, bLimburg Brain Injury Center, Maastricht, The Netherlands, cDepartment of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands, dCardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands, eDepartment of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands, fDepartment of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience (FPN), Maastricht University, Maastricht, The Netherlands
ABSTRACT
Traumatic brain injury (TBI) that requires Intensive Care Unit (ICU) treatment is associated with a high social and financial burden due to persisting (severe) disabilities. The consequences of TBI after ICU admission are generally measured with global disability screeners such as the Glasgow Outcome Scale-Extended, which may lack precision. In order to improve outcome measurement after brain injury, a comprehensive clinical outcome assessment tool called the Minimal Dataset for Acquired Brain Injury (MDS-ABI) was recently developed. The MDS-ABI covers twelve life domains (demographics, injury characteristics, comorbidity, cognitive functioning, emotional functioning, energy, mobility, self-care, communication, participation, social support, and quality of life), as well as informal caregiver capacity and strain. In this cross-sectional single center study, we administered the MDS-ABI during follow-up home visits to explore the relationship between dichotomized severity of TBI and long-term outcome. Our objectives were to: 1) summarize demographics, clinical characteristics, and long-term outcome, and 2) compare differences in clinical trajectories and long-term outcome between patients with mild-moderate TBI (mmTBI) and severe TBI (sTBI) based on Glasgow Coma Scale (GCS) scores at admission. Participants were former patients (n = 52) of a Dutch university hospital, who had been admitted to the ICU between six months and five years prior to the home visit, as well as their informal caregivers (n = 45). On average 3.2 years after ICU discharge, 62% of the patients were cognitively impaired, 62% reported elevated fatigue, and 69% experienced restrictions in ≥ 2 participation domains (most frequently work or education, and going out). Informal caregivers generally felt competent to provide necessary care (81%), but 31% experienced disproportionate caregiver burden. Almost all patients (92%) lived at home independently, often together with their informal caregiver (81%). The mmTBI group and the sTBI group had significantly different clinical trajectories. mmTBI patients had a shorter ICU stay (median = 5 days (interquartile range (IQR) = 2–14)) than sTBI patients (median = 11 days (IQR = 5.5–18)), p < 0.05 and, consequently, a shorter hospital stay (median = 12 days (IQR = 6.5–22) vs. median = 28 days (IQR = 13–36)). Patients with mmTBI were discharged home more frequently (n = 15, 68%) than patients with sTBI (n = 8, 28%). Contrastingly, at follow-up, there were no differences between the groups for patient or caregiver outcomes on the MDS-ABI. Our results suggest that, once patients survive TBI that requires ICU admission, chances are reasonable that they will return to living an independent life. However, a substantial proportion of patients and caregivers experience long-lasting consequences, which appear to be independent of injury severity, and extend beyond global disability or independent living. As these consequences may go unnoticed with the use of global disability screeners, the MDS-ABI may be a promising tool for comprehensive follow-up of TBI patients in the context of research and clinical care.
381 A manual-based family intervention for families with acquired brain or spinal cord injury: a danish randomized controlled trial
Pernille Langer Soendergaarda,b, Juan Carlos Arango-Lasprillac, Mia Moth Wolffbrandta, Frederik Lehman Dornonville de la Coura, Fin Biering-Sørensend,e, Anne Norupa,b
aNeurorehabilitation Research and Knowledge Center, Rigshospitalet, Glostrup, Denmark, bDepartment of Psychology, University of Southern Denmark, Odense, Denmark, cDepartment of Psychology, Virginia Commonwealth University, Richmond, USA, dDepartment of Brain and Spinal Cord Injuries, Rigshospitalet, Copenhagen University Hospital, Glostrup, Denmark, eDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
ABSTRACT
Background: Acquiring a brain (ABI) or spinal cord injury (SCI) constitutes a severe life change for the whole family, and the consequences can affect the overall family functioning negatively resulting in decreased quality of life (QoL) and increased caregiver burden. The paradigm of supporting the family after ABI or SCI has primarily been on psychosocial interventions focusing on the caregiver or the individual with the injury separately. However, improving family function must include the whole family.
Objective: To investigate the effectiveness of an eight-week manual-based family intervention developed for the whole family living with ABI or SCI.
Methods: A two-arm randomized controlled trial. Individuals (≥ 18 years) with moderate to severe ABI or SCI were recruited from two specialized rehabilitation units in East-Denmark between six-months to two-years after discharge. Recruitment period was 2018 to 2021, and individuals with ABI or SCI were randomly allocated to an intervention group (IG) or a control group (CG) (ratio 1:1) with their primary caregivers. IG received the manual-based family intervention, which relies on strategies from cognitive behavioral therapy and couples and family therapy. The content of the eight-weekly sessions included making meaning of the injury, shifting to a positive focus, managing emotions, communicating effectively, finding new solutions, and boundary making. CG received one psychoeducational session regarding the consequences of injury. Self-reported questionnaires on QoL measured with mental component summary scale from SF-36 and caregiver burden measured with caregiver burden scale were completed as primary outcome measures at baseline, at two- and eight-months follow-up.
Results: A total of 157 participants were included: 74 randomized to IG (completed by 60), and 83 to CG (completed by 69). Mean age in IG was 53.4 (SD 16.9) years, 53% males, 71% spouses or partners, 91% with length of relationship > 5 years, and 89% living together with the participating caregiver(s). Mean age in CG was 50.3 (SD 14.4) years, 49% males, 62% spouses or partners, 80% with length of relationship > 5 years, and 82% living together with the participating caregiver(s). In IG, 69% of the caregivers reported caring for the individual with the injury every day, which was 64% in CG. In IG, 71% reported spending between 1 to 5 hours each day on supervising, correspondingly with 64% in CG. The groups did not differ significantly on any baseline characteristics (all p’s > 0.05). Analyses on the outcomes of the trial are ongoing and will be reported at the conference.
Conclusion: The trial design was feasible and is currently being evaluated. The results of the ongoing analyses are expected to contribute with novel knowledge on the effectiveness of a manual-based family intervention.
382 Clinician perspectives on post-concussion syndrome following mild traumatic brain injury
Suvi Dockreea,b, Brian McGuireb
aNational Rehabilitation Hospital, Dun Laoghaire, Ireland, bUniversity of Galway, Galway, Ireland
ABSTRACT
Interpretations about the etiology and treatment needs for post-concussion syndrome (PCS) divide opinions in research and clinical practice. This study explored multidisciplinary clinicians’ experiences and perceptions of PCS, and their recommendations for service delivery and professional development. Qualitative thematic analysis was conducted using online focus groups and individual interviews. Participants were purposively selected from a national outpatient brain injury rehabilitation service and from selected hospitals within Dublin, Ireland. Data yielded four main themes and eight sub-themes. The main findings were coded into the following themes: 1) complex and multifactorial, 2) foundations for a better service, 3) clinicians’ experiences, and 4) prevention is better than cure. Participants, irrespective of discipline, found that PCS was best contextualized within the biopsychosocial model of injury. Consistent with previous research psychological difficulties, lack of support and validation, and the nature of an invisible injury, were found to perpetuate post-concussion symptoms. Prevention of pervasive symptoms through early provision of information and reassurance was perceived as essential. Nonetheless, current findings highlight inadequate access to early support, lack of clear service pathways, and need for specialist interdisciplinary approach. Furthermore, clinicians involved in the acute recovery phase lack sufficient resources to carry out comprehensive assessment and treatment of PCS. Upskilling of staff, timely access, and integrated care through established referral pathways from acute care to specialist interdisciplinary services are required. Implications for future studies and service development, with reference to Slaintecare (an Irish ten-year programme to transform health and social care services) are discussed.
Keywords: mild traumatic brain injury, post-concussion syndrome, biopsychosocial, clinician perceptions, interdisciplinary, integrated care, prevention
383 Ireland’s first level 2 neuro-rehabilitation demonstrator site as part of a managed clinical rehabilitation network – a review of outcomes after 24 months
Siobhan Kennya, Karen O’Connella, Eugene Wallacea, Catherine Slatterya, Mini Mary Paula, Nuala Crossa, Griffin Clarea, Anne Kehoea, Sinead McCaffreya, Kate Prendivillea, Jacinta McElligotta
aPeamount Healhtcare, Newcastle, Ireland
ABSTRACT
Introduction: Neuro-rehabilitation is a dynamic and critical component of the therapeutic continuum. It is well established that earlier access to rehabilitation services after illness or injury is associated with better functional outcomes and quality of life. The development of local specialist rehabilitation services is an integral part of the National Strategy and Policy for the Provision of Neuro-Rehabilitation Services in Ireland. In September 2020 the first level 2b inpatient specialist neuro-rehabilitation service opened at Peamount Healthcare. This unit was a demonstrator site Ireland’s first Managed Clinical Rehabilitation Network (MCRN). The model of service delivery has been designed and implemented with a view to replicating across other MCRN sites nationally. This audit was done to assess outcomes to date.
Methods: Data was collected on all patients admitted between September 2020 and August 2022 and included demographics, diagnosis, rehabilitation complexity score (RCS), length of inpatient stay, functional outcomes measures and patient reported outcomes. Functional outcome measures included the Functional Independence Measure and Functional Assessment Measure (FIMFAM), and the Northwick Park Dependency Scale (NPDS) which have been validated for use in this context. Patient reported outcomes were assessed using the Euro-Qol-5D −5L (EQ5D). All data was analyzed using excel or SPSS V26.
Results: There were a total of 112 admissions over the study period. Sixty-six percent were male (n = 74). The median age was 53 years (range: 18–70 years). Thirty-six percent had an admission RCS ≥ 11 indicating a high level of complexity. The most common indication for admission was post-stroke (53%). Median length of stay was 46 days (range: 4–139 days). The NPDS improved between admission and discharge (mean change: 7, 95% CI: 5,8, p < 0.001), with 60% of people considered independent for care needs on admission increasing to 85% by discharge. FIMFAM scores also showed significant improvement on discharge (mean increase: 29, 95% CI: 16, 42, p < 0.001). Improvements in each domain of the EQ5D was seen between admission and discharge with: 42% v 81% reporting no or slight limitation in mobility, 61% v 89% reporting no or slight difficulty with washing and dressing, 33% v 67% reporting no or slight difficulty doing their usual activities, 58% v 70% reporting no or slight pain or discomfort and 68% v 87% reporting no or slight anxiety or depression. A significant improvement in their self-reported overall health status was also seen (mean change: 18, 95%CI: 13, 42, p < 0.001) with 71% reporting overall health status of >70/100.
Conclusion: This audit has demonstrated improvements across all outcome measures for patients, representing better functional outcomes and improved perceived quality of life on discharge. Peamount’s neuro-rehabilitation service facilitates earlier access to neuro-rehabilitation and can be replicated successfully in other Community Health Organizations (CHOs) in line with plan for the MCRN.
386 Remote cognitive testing in pediatric traumatic brain injury: gold-standard neuropsychology and automated online digital assessments
Niall Bourkea,b, Célia Demarchib, William Trenderb, Adam Hampshireb, David Sharpb
aKing’s College London, London, United Kingdom, bImperial College London, London, United Kingdom
ABSTRACT
Pediatric traumatic brain injury (TBI) is a common cause of long-term disability in children, affecting between 42 and 280 per 100,000 children (Dewan et al., 2016). Health services are facing an unprecedented level of demand and most children do not currently access clinical neuropsychology after their injury. Unrecognized and unsupported effects post pediatric TBI can lead to difficulties in school and a widening gap in learning compared with healthy peers. One barrier to clinical neuropsychological assessments being offered to all children post-TBI is that they are costly and labor intensive, requiring in-person administration and clinician time, with lengthy assessment protocols utilizing various pieces of equipment. Online cognitive assessments have been steadily gaining interest pre-2020, with their place in healthcare accelerated by the COVID-19 global pandemic. Their potential to be rapidly deployed, at scale, remotely has been described in large population samples (Hampshire et al., 2021), but less is known about their application in pediatric clinical settings. The aim in the current work is to compare gold-standard neuropsychology assessments with automated online digital tasks in order to determine the utility of remote digital assessments for screening of cognitive difficulties.
Gold-standard neuropsychology assessments, including measures of memory, executive functioning and wellbeing were performed in young healthy controls (n = 21) and young people that have sustained a traumatic brain injury (n = 24). This cohort also completed an automated online battery of digital assessments (Minder tests) aligned with the neuropsychology assessments. An additional large cohort of independent age-matched controls from the general population also completed the digital Minder tasks online unsupervised as part of a wider study (n ~ 300,000).
Young people that have sustained TBI showed lower performance in a range of standard and digital neuropsychological assessments including memory, executive function and verbal comprehension as well as lower reported wellbeing. A strong correlation is seen between similar gold-standard neuropsychological assessments and remote Minder neuropsychology tasks. For example, WASI2 vocab and Minder word definitions (R = 0.69, p < 0.001); pen and paper Trail making B and Minder trail making B (R = 0.65, p < 0.001).
In person assessments benefit from building rapport, controlled conditions and may involve longer comprehensive batteries. However, with limited resources accessing this input is challenging and not always prioritized by level of need. A delay in getting access to services and adequate support can have a drastic impact on a young person’s development. Short digital assessments can triage ahead of formal assessments and flag immediate concerns in wellbeing. Remote digital testing can be a useful additional tool to assist in assessment and potentially inform clinical management.
387 The effectiveness of group compassion focused therapy for acquired brain injury survivors
Elaine Kellya, Claire McMorelanda, Fiona Ashworthb, Ciarán Nolana, Megan Devereuxa, Bríd Fogartya, Deirdre Murphya, Laoise Kelma, Caoimhe Carolana, Tara Junghenna, Rebekah McLoughlina
aHeadway, Dublin, Ireland, bDepartment of Neuropsychology and Clinical Health Psychology, Atkinson Morley Wing, St George’s University Hospital, NHS Foundation Trust, London, United Kingdom
ABSTRACT
Rates of depression and anxiety are higher amongst acquired brain injury (ABI) survivors than in the non-brain injured community. However, current treatments for these symptoms can have limited effectiveness. A promising treatment is Compassion Focused Therapy (CFT) which is a third-wave behavioral therapy. CFT was originally developed for people with high levels of self-criticism and shame, which often occur in the context of depression and anxiety. CFT draws on neuroscience and evolutionary theory to identify the main emotional systems in the human brain and to bring them into greater balance. When confronted with life difficulties, the way we make attributions of causality for those setbacks (e.g. self-blame vs. self-compassion) and the way we evaluate, judge, condemn or accept, and support ourselves has a major impact on our coping and recovery. The 3 main tenets of self-compassion; self-kindness, a sense of common humanity, and mindfulness are considered particularly salient for survivors of ABI as they are often faced with a different and uncertain future where being compassionate toward oneself can offer psychological protection. Single case research and feasibility studies in the past decade have demonstrated that CFT holds significant promise as an intervention for survivors of ABI. This study aimed to examine the effectiveness of a CFT group therapy for individuals with ABI presenting with high self-criticism, low capacity to self-sooth and co-occurring anxiety and/or depression. 46 participants (28 male, 18 female) completed a 10-week CFT group therapy in a community-based neurorehabilitation service. Six groups in total were carried out. Of the 46 participants who were offered the intervention, 41 completed measures of self-criticism, inadequacy/self-hatred, self-compassion, satisfaction with life, anxiety and depression, at pre-treatment, post-treatment, and at 3-month follow-up. Preliminary efficacy was assessed via a one-way repeated measures analysis of variance (ANOVA). Effect sizes were also calculated. Significantly greater improvements were found for levels of perceived personal inadequacy, self-criticism, compassion for self, satisfaction in life and depression and these gains were maintained at 3 months. Reductions in anxiety and self-hatred did not reach statistical significance at post-intervention or follow-up, albeit from a low baseline. The findings from this study provides further evidence that CFT appears to be an effective group intervention for individuals with ABI, particularly where high self-criticism and depression is a feature. Routine assessment of self-criticism and self-compassion might be beneficial to neurorehabilitation teams in understanding client’s psychological needs and how to target intervention. Further research is needed to explore the benefits of CFT in ABI using more detailed analysis and RCTs.
388 Disability from head injury in male juveniles in prison in Scotland and relationships with cognitive function, and crime
Tom McMillana, Julia McVeana, Hira Aslama, Sarah Barryb
aUniversity of Glasgow, Glasgow, United Kingdom, bUniversity of Strathclyde, Glasgow, United Kingdom
ABSTRACT
Introduction: The prevalence of head injury is thought to be high in juvenile prisoners, however the extent of persisting disability is not known and relationships with offending are uncertain and likely to be complex. This limited understanding makes service development geared toward effective management and interventions for health needs or to reduce recidivism difficult. In this study we investigate effects of head injury on cognitive function, disability and offending in juvenile prisoners, and relationships with comorbidities.
Methods: Male juvenile prisoners in Scotland were recruited. Assessment using the Ohio State University- TBI method determined whether there was a history of significant head injury. The Glasgow Outcome at Discharge Scale was used to assess disability. History of abuse, mental health and problematic substance use was assessed by interview and questionnaire. Data were analyzed using linear and logistic regression models.
Results: We recruited 103 juvenile males. Comparisons were made between juveniles with and without a history of significant head injury. The sample was demographically representative of juvenile males in prisons for young offenders in Scotland and comprised one third of juveniles in prison in Scotland. Significant head injury was found in 82/103 (80%) including head injury repeated over long periods of time in 69/82 (85%). Disability was associated with SHI in 11/82 (13%) and was significantly associated with mental health problems. Significant differences between groups on cognitive tests were not found. The SHI group reported poorer behavioral control on the Dysexecutive Questionnaire and had more often been reported for incidents in prison than those without SHI. Groups did not differ in characteristics of offending, including violence. Interpretation: Although a history of significant head injury was very prevalent in juvenile prisoners, disability associated with head injury was relatively uncommon. In addition, cognitive test performance or offending characteristics did not differ between juveniles with and without a history of significant head injury. There were however signs of poorer control of behavior and greater psychological distress in juveniles with a history of significant head injury suggesting that a risk of recidivism may be higher. Hence remedial programmes for juvenile prisoners need to take account of persisting effects of head injury to improve the understanding of prisoners about effects of head injury and reduce future risk of cumulative effects.
389 Association between swallowing disorders and patients with disorders of consciousness (DOC): oral feeding recovery
Valentina Bonsanguea, Ambra Balzeria, Sofia Straudia, Marina Maccaa, Silvia Carlia, Fabio Scagliaa, Rossella Scatozzaa, Susanna Lavezzia
aBrain Injury Rehabilitation Unit, Ferrara Hospital, Cona, Ferrara, Italy
ABSTRACT
Background: Disorders of consciousness (DOC) after severe acquired brain injury are associated with multiple impairments and have a significant impact on public health related costs. Swallowing disorders are relatively frequent in DOC and increase the risk of malnutrition, dehydration, and respiratory infections.
Objective: The aim of this study was to investigate the incidence of dysphagia and oral feeding recovery in DOC. Moreover, we analyzed the association between type of feeding and prolonged DOC (unresponsive wakefulness syndrome UWS and minimally conscious state MCS) and the respiratory status at admission and discharge. We evaluated the link between the subscale oromotor functions in Coma Recovery Scale-Revised (CRS-R) and type of feeding.
Methods: We retrospectively analyzed a database that includes patients with DOC and swallowing disorders. We included patients who were admitted to the Ferrara Neurorehabilitation Unit between January 2020 and September 2022 for a multidisciplinary rehabilitation program. We investigated the level of consciousness, measured by the Coma Recovery Scale – Revised (CRS-R), the type of feeding, the occurrence and type of tracheostomy tube (tracheostomy cuff inflated, closed tube and removed) at admission and discharge.
Results: We included 25 severe brain injury individuals (traumatic 13, hemorrhage 6, anoxia 2, ischemic 1) with DOC (76% UWS and 24%MCS). At admission all patients were fed by enteral alimentation tube (100%) and 21 presented tracheostomy tube (84%). At discharge we observed 36% UWS and 64% MCS. 32% of MCS patients showed therapeutic feeding at discharge, whereas none of the UWS recovered. Those patients had also a favorable respiratory outcome, given that 3 removed and 2 closed tracheostomy tube. In this sample, the CRS-R oromotor domain reported both oral movements and vocalizations at discharge.
Conclusion: All DOC participants had severe dysphagia at admission to the rehabilitation setting requiring a specific and appropriate rehabilitation care. Only MCS were able to recover a therapeutic feeding at discharge, concurrently with the tracheostomy removal. To recovery oral feeding is probably necessary a higher level of consciousness, considering relation between the level of consciousness and swallowing function.
390 Elderly mild traumatic brain injury patients: a cognitive profile
Nikki Thussa, Sandra Rakersa, Joke Spikmana, Joukje van der Naalta
aUniversity Medical Center Groningen, Groningen, Netherlands
ABSTRACT
Objective: Mild traumatic brain injury (mTBI) generally has a good prognosis. Objective cognitive impairments in information processing speed, attention and memory can be present in the (sub)acute phase after injury, but they are found to recover completely at 3-months post-injury in the overall population. Still, a substantial proportion of patients experience persistent subjective cognitive complaints in the chronic phase after injury. Elderly mTBI patients differ from the overall population in injury mechanisms and proneness to secondary damage due to age-related changes in the brain, emphasizing the need to investigate them as a separate group. Given the rapidly aging population, more elderly will encounter mTBI. We aimed to examine the cognitive impairment, cognitive complaints and their association in elderly mTBI patients.
Participants and Methods: A total of 52 mTBI patients aged 61 to 88 years (M = 71.5, SD = 6.9) at the time of injury and 42 healthy controls aged 60 to 80 years (M = 67.3, SD = 4.8) participated in the current study. The groups were controlled for sex and educational level. The Head Injury Symptom Checklist was administered to measure cognitive complaints (forgetfulness, concentration problems, slowness). Cognitive functions were measured only in patients by administering a neuropsychological test battery at a mean of 3,5 months post-injury (SD = 1, range = 2–6). The following cognitive domains were assessed: memory and attention, processing speed and executive control. A percentile score of 10 or lower on a neuropsychological test was considered impaired. The percentile scores on the neuropsychological tests were compared to a median of 50.
Results: Results showed that elderly mTBI patients experienced more often complaints of forgetfulness (p = 0.003) concentration problems (p = 0.029) and slowness (p < 0.001) than healthy controls. Additionally, cognitive impairment was found in 40% of the patients for tasks in the domain of memory and in 29% for tasks in the domain of attention, processing speed and executive control. A significant, moderate negative correlation was found between complaints of concentration and a test in the domain of executive functions (Rs = −0.418, p = 0.003).
Conclusions: These findings show that elderly patients have cognitive impairments in the domain of memory and attention, processing speed and executive control. Also, they experience persistent cognitive complaints of forgetfulness, concentration problems and slowness after suffering from mTBI. Increased complaints of concentration are associated with decreased performance in the domain of executive functions. In contrast, this relationship is lacking between complaints of forgetfulness and tasks in the domain of memory. In conclusion, this subgroup of elderly mTBI patients have cognitive impairment and cognitive complaints in the subacute phase after injury.
391 Synaptic activity and neuroprotection through synaptic cytokine
Shun Lia, Florian olde Heuvela, Rida Rehmana, Oumayma Aousjia, Albrecht Froehlicha, Zhenghui Lia,b, Francesco Rosellia,c
aDepartment of Neurology, Ulm University, Ulm, Germany, bDepartment of Neurosurgery, Kaifeng central Hospital, Kaifeng, China, cGerman Center for Neurodegenerative Diseases (DZNE)-Ulm, Ulm, Germany
ABSTRACT
New progress in cytokine studies has focused on well-defined cytokines involved in cell signaling and central nervous system physiology. Multiple cytokines are released in the brain parenchyma upon brain trauma, affecting not only glial and inflammatory cells, but also neurons and neuronal function. Some of these cytokines may be produced by neurons, implying that they may have nonimmune functions in neuronal cells.
We recently found that interleukin-13 (IL-13) is upregulated upon brain injury and has a neuronal origin. However, it is unknown which role IL-13 plays in neuronal physiology in health and disease.
To identify the neuronal source of IL-13 and its effect on neuronal physiology, we used confocal and super-resolution STED microscopy, subcellular fractionation, a phospho-array platform, fluorescent single molecule in situ hybridization, electrophysiology, and label-free live cell imaging.
In mice, rats, and humans, we show that IL-13 and its receptor are expressed by neurons and reveal a pre- and post-synaptic localization respectively. Furthermore, we indicate that IL-13 causes a cascade of signaling events in neurons which results in glutamate receptor phosphorylation, an increase in excitatory post-synaptic potential, the induction of presynaptic and postsynaptic plasticity, phosphorylation of transcription factors (most prominently CREB), and the activation of plasticity-related and anti-apoptotic transcriptional responses. We demonstrate that IL-13 is upregulated in mice after a blunt head injury in an activity-dependent manner. Ultimately, we have used label-free holotomography live cell imaging to show that low doses of IL-13 reduce neuronal vulnerability to excitotoxic death while high doses had no effect.
Our findings indicate that IL-13 is a previously unknown physiological modulator of neuronal and synaptic function, with implications for the establishment of synaptic plasticity and neuronal survival under injury conditions. Thus IL-13 offers a novel, dose-dependent neuroprotective pathway for brain injury.
392 Estimating the gross motor change associated with inpatient rehabilitation for school-aged children and youth with acquired brain injury: a 10-year retrospective review
Jennifer Ryana,b, Chuanlin Zhoua, Danielle Levacc, Darcy Fehlingsa,b, Deryk Beala,b, Ryan Hunga, Virginia Wrighta,b,d
aHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, cSchool of Rehabilitation, University of Montreal, Montreal, Canada, dDepartment of Physical Therapy, University of Toronto, Toronto, Canada
ABSTRACT
Introduction: While children with moderate to severe acquired brain injury (ABI) often make considerable gains in gross motor function with inpatient rehabilitation during the subacute stage, they also experience plateaus in recovery and contend with long-term motor deficits that impact their participation in meaningful activities. As such, there is an interest in exploring new treatment approaches with the goal of enhancing gross motor outcomes during the subacute stage of recovery where there is strong potential to influence neuroplasticity. However, there is limited published documentation of the gains associated with inpatient physiotherapy using standardized clinical assessments, data that would permit preliminary comparison between novel and traditional interventions in feasibility studies and could be used to calculate sample sizes for appropriately powered clinical trials. Thus, the objectives of this study were to estimate the gross motor change in inpatient school-aged children with subacute ABI using standardized physiotherapy assessments, identify factors associated with gross motor change, and describe inpatient physiotherapy goals.
Method: This retrospective chart review involved inpatient children (5–18 years) with subacute ABI at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada) who had either two Gross Motor Function Measure (GMFM-88) assessments or one GMFM-88 with another pre/post gross motor outcome measure. Outcome change scores and Goal Attainment Scaling (GAS) T-scores were calculated. Stepwise regression analyses examined factors predicting gross motor change using the GMFM-88, Six-minute Walk Test (6MWT), and Community Balance and Mobility Scale (CB&M). GAS goal areas were analyzed to determine physiotherapy focus.
Results: Of the 546 charts that met preliminary diagnostic, age, and length of stay (i.e., minimum six weeks) criteria, 266 (118 female) were eligible. The diagnostic categories of eligible charts were: stroke (n = 84), brain tumor (n = 63), traumatic brain injury (n = 42), post-epilepsy surgery (n = 33), post-infectious (n = 18), neuroinflammatory (n = 15), and hypoxia (n = 11). Physiotherapists usually administered the GMFM-88 first, followed by other measures. Baseline GMFM-88 scores varied 0–100%. GMFM-88 (n = 202), CB&M (n = 89), and 6MWT (n = 98) mean change scores were 18.03% (SD = 19.34), 17.85% (SD = 10.77), and 142.3 m (SD = 101.8), respectively. Lower baseline scores and increased time between assessments were predictive of greater GMFM-88 and 6MWT change. Age and sex were significant predictors of 6MWT change but not GMFM-88 or CB&M change. The mean GAS T-score was 55.06 (SD = 11.50). GAS goal areas varied depending on baseline GMFM-88 score. While 25% of GAS goals were ambulation-based, goals also focused on other gross motor skills, balance, functional strength, coordination, and endurance.
Conclusions: The GMFM-88, 6MWT, and CB&M mean change scores from this review can serve as reference points to compare traditional inpatient physiotherapy with new treatment approaches. While inpatient physiotherapy focuses on ambulation, physiotherapists address multiple aspects of gross motor function.
393 Relative contribution of cognitive and motor functioning on community integration one year after TBI
Chad Swanka, Dmitry Esterovb, Monica Bennetta, Flora Hammondc,d, Kristen Dams-O’Connore,f
aBaylor Scott & White Research Institute, Dallas, USA, bDepartment of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, USA, cIndiana University School of Medicine, Indianapolis, USA, dRehabilitation Hospital of Indiana, Indianapolis, USA, eDepartment of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, USA, fDepartment of Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
ABSTRACT
Background and Purpose: The relative contributions of motor and cognitive functioning on outcomes after Traumatic Brain Injury (TBI) are poorly understood. We investigated the hypothesis that motor and cognitive abilities during inpatient rehabilitation will have independent and interactive associations with community integration and functional independence measured at 1-year post-TBI.
Methods: Secondary data analysis of 779 participants in the TBI Model Systems National Database who experienced a moderate-severe TBI requiring inpatient rehabilitation. Participants were categorized as low motor/low cognition (n = 358; 46.0%), low motor/high cognition (n = 30; 3.9%), high motor/low cognition (n = 329; 42.4%), or high motor/high cognition (n = 62; 8.0%) based on Functional Independence Measure (FIM) and Brief Test of Adult Cognition by Telephone (BTACT) scores collected near rehabilitation admission and assessed on outcomes [Participation Assessment with Recombined Tools-Objective (PART-O), driving, Supervision Rating Scale, residence, re-injury, and employment status] 1-year post-injury.
Results: Compared to those with low motor/low cognition 1-year following TBI, participants with high motor/high cognition and high motor/low cognition had higher scores on PART-O total score (p < 0.001 and p = 0.010, respectively) and higher odds of driving (p = 0.003 and p = 0.009) and re-injury (p = 0.001 and p = 0.003). Additionally, participants with high motor/high cognition had higher odds of employment at one year (p = 0.003), and participants with low motor/high cognition had higher odds of living independently (p = 0.049) when compared to low motor/low cognition.
Discussion and Conclusions: Regardless of cognitive status, high motor function at rehabilitation is associated with favorable community integration outcomes 1-year post-injury, though greater participation afforded by high motor function may confer elevated risk of re-injury.
394 Effectiveness of education strategies for prevention of concussion
Caithriona Yeomansa, Richelle M Williamsb, David Mocklerc, Fiona Wilsonc
aIrish Rugby Football Union, Ballsbridge Dublin 4, Ireland, bDrake University, Des Moines, U.S.A, cTrinity College Dublin, Dublin, Ireland
ABSTRACT
The incidence of sport-related concussion varies across athletic populations and sporting codes, with increases observed annually over the past two decades. This increased incidence has led to a renewed focus on athlete management, rehabilitation, and prevention. Concussion prevention strategies may reduce the number and severity of concussions, however, the effectiveness of strategies incorporating concussion education is relatively unknown.
Aim: To examine the effectiveness of education strategies in the prevention of sports-related concussions.
Methods: Systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. The protocol for this systematic review was registered on PROSPERO (285073). Studies were identified by applying a comprehensive search strategy in the following electronic bibliographic databases: MEDLINE via PubMed, EMBASE via Ovid, CINAHL via EBSCO, Web of Science and Scopus, from inception to November 2021. Athletic populations of any sex, gender, age and level of activity or competition were included. All types of trials, including; randomized and quasi-randomized trials, cohort (prospective or historical), observational and cross-sectional studies were eligible to start. Primary outcomes of interest were: concussion incidence, concussion severity, and concussion knowledge, with secondary outcome measures of self-reported attitudes and objective behavior changes. Eligible studies were critically appraised using the Newcastle Ottowa scale for observational studies and the Cochrane risk of bias tool for randomized control trials. Study characteristics, outcomes, and methodological quality were synthesized.
Results: Twenty-six studies with a total of 8,687 participants (men n = 5,632, women n = 3,051, not disclosed n = 4) were included. Concussion education strategies were investigated in a variety of cohorts, with ice hockey being the most common (n = 8), followed by soccer and basketball (n = 4 each). All studies included concussion knowledge and self-reported attitudes as primary outcome measures, with six studies using the Rosenbaum Concussion Knowledge and Attitudes survey. Other outcome measures included concussion incidence and reporting (n = 5) and behaviors (n = 3). The majority of studies (n = 18) reported significant improvements in concussion knowledge immediately post intervention however half of these studies did not find that improvements in knowledge were retained at follow-ups of 3–12 months. Eight studies compared education delivery methods, finding that video resources (n = 5), interactive workshops (n = 3) or peer-led sessions (n = 1) resulted in significant increases in concussion knowledge compared to written resources alone.
Conclusion: Education strategies can increase knowledge and self-reported attitudes toward concussion, however these results were not retained at follow-up. Improved concussion knowledge does not automatically lead to appropriate changes in behavior or concussion reporting. Concussion education programmes should target intention to report behavior in order to reduce concussion injury risk and incorporate regular follow-up to ensure knowledge retention. An important consideration is that the effectiveness of a prevention strategy may be dependent on the programme delivery, not the efficacy of the educational materials themselves.
395 Identifying prolonged inpatient admissions in children with acquired brain injury: a use of the rehabilitation complexity scale
Orla McNerneya, Jillian Pouncha, Irwin Gilla,b,c
aChildren’s Health Ireland at Temple Street, Dublin 1, Ireland, bNational Rehabilitation Hospital, Dublin, Ireland, cSchool of Medicine, University College Dublin, Dublin, Ireland
ABSTRACT
Background: The Rehabilitation Complexity Scale was developed for use in adults to provide a measure of the complexity of a person’s rehabilitation needs. Its use has been described in children, but it has not yet been validated for pediatric populations. We aimed to identify the point at which children with acquired brain injury admitted for 28 days or longer to a tertiary acute hospital were suitable for discharge based on RCS scores, but remained in hospital to access ongoing intensive therapy input. We aimed to investigate correlations between initial Rehabilitation Complexity Scale (RCS-E) score and length of inpatient admission.
Methods: RCS-E is administered as standard within one week of admission for all patients accessing the Acute Rehabilitation Service in Children’s Health Ireland at Temple Street. Data pertaining to initial RCS-E scores and length of inpatient admission were extracted from the rehabilitation database. We sought to identify the date at which patients were suitable for discharge from a medical/ nursing perspective, as determined by an RCS ‘Medical Needs’ score of M0/M1 and a ‘Skilled Nursing Needs’ score of N0/N1/N2. Admissions of 28 days or longer has been interpreted as inferring the occurrence of a “probable severe ABI requiring rehabilitation (PSABIR).” RCS-E scores for patients with admissions of 28 days or longer were compared to those admitted for less than 28 days. Independent t-test was performed. All admissions were divided into brackets based on initial RCS-E score (0–4, 5–9, 10–14, 15–19, 20–25). The Kruksal-Wallis test was performed to test for differences between the medians of the groups.
Results: Forty completed admissions were noted from June 2021 to February 2022. Initial RCS-E scores for patients admitted for 28 days or longer were higher than those of patients admitted for less than 28 days (18.67 v 9.77, p < 0.001). Length of stay (LOS) was correlated with initial RCS-E score. Median LOS for RCS-E 0–4 was 2 days, increasing to 8 days for RCS-E 5–9, 11 days for RCS-E 10–14, 26 days for RCS-E 15–19 and 78 days for patients with initial RCS-E scores of 20 or higher (test statistic h = 27.29, critical chi-square value 9.49). For patients admitted for over 28 days, total length of hospital stay ranged from 42 to 184 days (mean 87 days). Length of stay after patients were fit for discharge based on RCS scores ranged from 1 to 70 days (mean 28 days). Prolonged admissions accounted for a minimum of 307 extra bed days per year.
Conclusion: Higher initial RCS-E scores are associated with longer inpatient admissions. RCS scores allowed for identification of the point of readiness for discharge; the potential to reduce bed occupancy may be useful in service development initiatives including the development of day rehabilitation services.
396 Toward documenting the recovery of communicative interactional skills through disorders of consciousness and post-traumatic confusion – engaging rehabilitation staff as stakeholders
Annesofie Ishøy Nielsena,b, Rineke Brouwerb, Jytte Isaksenb, Anne Norupc,d
aDepartment Of Brain Injury – TBI unit, Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark, bDepartment of Language and Communication, University of Southern Denmark, Odense, Denmark, cNeurorehabilitation Research and Knowledge Center,Copenhagen University Hospital/Rigshospitalet, Copenhagen, Denmark, dDepartment of Psychology, University of Southern Denmark, Odense, Denmark
ABSTRACT
Objective: Severe TBI leads to disorders of consciousness, post-traumatic confusion, cognitive impairments, and in relation to this impaired communicative interaction. During subacute rehabilitation, patients’ level of consciousness increases, and, simultaneously, the patients’ abilities for interacting with the surroundings might return, e.g., the ability to answer questions. However, we lack systematic description of these patients’ interactive abilities through post-traumatic amnesia (PTA) since no qualified assessment tool exists. Hence, the aim of this study was to explore the experiences of rehabilitation staff, who interact with patients in PTA on a regular basis and how these experiences inform such a systematic description.
Method: The reported study serves as the first round in a process using Nominal Group Technique (NGT) to actively engage stakeholders. Staff members from a subacute rehabilitation setting, with minimum two years of experience working with patients in PTA were invited to participate. Steps were taken to ensure participation from staff meeting patients in different kinds of activities covering day and night shifts. In a structured face-to-face meeting, participants individually noted down their perspectives on interacting with patients in PTA and were subsequently encouraged to share their perspectives in a round-robin format ensuring time for discussions and swift agreement on key topics. Transcribed audio-recordings were analyzed using Braun and Clarke’s Reflexive Thematic Analysis (Braun & Clarke, 2006, 2020).
Results: Six different professions participated (nurses, nurse assistants, physiotherapists, occupational therapists, speech-language therapists, and neuropsychologists) including a total of 22 rehabilitation professionals. Length of experience working with patients in PTA ranged from 2–22 years. The analysis showed the following overarching themes: a need for knowledge of pre-/post-injury patient characteristics in order to support the interaction (e.g., personal communication style, consciousness level, reliable yes/no-answers), providing what the patient needs of support to be able to interact in rehabilitation activities (e.g., giving verbal and written choices), and paying attention to specific areas of patients’ reactions (e.g., establishing and maintaining eye contact).
Conclusion: Engaging rehabilitation staff as stakeholders provided valuable insights. When asked about their perspectives on interacting with patients in PTA, participants shared observations of patients’ characteristics but in addition valued a range of their own needs for knowledge and information needed to provide support in the communicative interactions. These needs expressed by participants align with the needs of a patient group relying heavily on their surroundings to participate in communicative interactions. A documentation of patients’ emerging skills for engaging in communicative interaction in subacute rehabilitation requires staff involvement. Hence, the needs expressed by participants should feed into the subsequent rounds of NGT working toward an observational tool for systematically describing the patients’ recovery of communicative interactional skills through disorders of consciousness and post-traumatic confusion.
397 Rehabilitation of working memory after traumatic brain injury (TBI): cognitive and MRI case series study (PLASTIM-MDTC)
Guillaume Mazoa, Stéphanie Pantaléoa,b, Jean-Luc Picqa, Lucie Hertz-Pannierc, Eric Brunetd, Philippe Azouvid,e, Claire Vallat-Azouvia,b
aDysCo Laboratory, Paris 8 University, Saint-Denis, France, bAntenne UEROS-UGECAMIDF, Raymond. Poincaré Hospital, Garches, France, cCognitive Neuroimaging Unit, CEA, INSERM, Paris-Sud University, Paris-Saclay University, NeuroSpin Center, Gif/Yvette, France, dParis-Saclay University, UVSQ, Inserm, CESP, UMR 1018, Team DevPsy, 94807, Villejuif, France, eAP-HP, GHU Paris-Saclay, Raymond. Poincaré Hospital, Department of Physical Medicine and Rehabilitation, Garches, France
ABSTRACT
Introduction: Working memory (WM) disorders often persist long time after an acquired brain injury (ABI), and involve difficulties in daily life. For several decades, methods of cognitive rehabilitation and training in healthy subjects have been developed. But contrary to the literature on healthy subjects, to date there are still very few studies evaluating the cerebral correlates of rehabilitation in patients with ABI. The objective of this study is to study the effects of cognitive rehabilitation on brain plasticity.
Methods: PLASTIM-MDTC is a study with a repeated single case experimental design on individuals with moderate to severe TBI. After two baseline cognitive assessments, patients underwent WM rehabilitation during 3 months (3/week). The effectiveness of rehabilitation was evaluated post-rehabilitation and after 3 months. A multimodal MRI was performed before and after rehabilitation.
Preliminary Results: We will present the results obtained for 3 patients. The results showed an effectiveness of rehabilitation on the behavioral level and an evolution of the functional activation profile on MRI during an n-back task. Primary outcome measures showed an average improvement in the Brown-Peterson task and a mean decrease in complaints in daily life related to WM. However, the evolution profile differed from one patient to another, with higher improvement in patients with more severe baseline impairments, variability between outcome measure in post and 3 months follow-up assessment, and different fMRI n-back evolution profile (decrease or increase). Interestingly, a far transfer in long-term memory appears in some patients, especially during the 3-months follow-up.
Discussion-Conclusion: The preliminary results of the PLASTIM study are in agreement with those observed in the repeated case studies of Hubacher et al (2015) on MS patients. The continuation of this research should make it possible to study the different evolution profiles and contribute to the search for early markers of the effectiveness of rehabilitation.
398 Brain injury survivors through the eyes of the Irish public
Andrea Healya, Catherine Fassbendera
aDublin City University, Dublin, Ireland
ABSTRACT
Background: Brain injury is a major public health concern; according to the World Health Organization, brain injury will become a major cause of death and disability worldwide by 2020. In 2018 in Ireland, the Major Trauma Audit, National Report 2018, reported head injuries as accounting for 18% (n = 1818) of all major trauma injuries. Despite the high incidence rate of brain injury, research suggests that the general public lack adequate knowledge about brain injury, resulting in misconceptions. This study investigated the views held by the general public in Ireland toward survivors of brain injury.
Methods: This research was a mixed-methods, cross sectional study. Survey questionnaires were administered to the general public electronically (N = 760). The survey comprised of the Brain Injury Misconception Scale (BIMS) to determine endorsed misconceptions about brain injury and qualitative questions sought to assess the general public’s understanding, knowledge and perception of brain injury.
Results: The average accuracy rate for correct responses was 62.62% (S.D. = 0.115). Greater than 80% of participants correctly responded to 5 out of the 17 statements. A hierarchical linear regression was conducted to evaluate the prediction of overall accuracy scores from age, gender, education level and experience of brain injury. At stage three of the regression model, all variables were significant predictors of overall accuracy on the BIMS (F (2,739) = 8.014 p < 0.0001). Content analysis revealed a high level of knowledge pertaining to causes of head injury and largely negative public attitudes were identified when asked about the difficulties brain injured survivors face in the community.
Discussion: There is an underestimation of the memory deficits following a brain injury and inaccurate beliefs relating to the complexities of the recovery process following a brain injury, education of the general public is therefore paramount. Greater public awareness of the reality of life after a brain injury will enhance the efforts of specialized services, and enable survivors of brain injury overcome challenges they face in the community.
399 Report of early childhood traumatic injury observations & symptoms (reactions) inventory: better detection of post-concussive symptoms in preschoolers
Dominique Duponta,b, Isabelle Gagnonc, Keith Yeatesd, Sean Rosee, Cindy Beaudoina, Jocelyn Gravelb, Brett Burnsteinc, Antonia Stangd, Rachel Stanleye, Miriam Beauchampa,b
aUniversité Of Montréal, Montreal, Canada, bCHU Sainte-Justine, Montreal, Canada, cMontreal Children’s Hospital, Montreal, Canada, dAlberta Children’s Hospital, Calgary, Canada, eNationwide Children’s Hospital, Columbus, USA
ABSTRACT
Introduction: Children aged 5 years and younger have the highest incidence of presentation in emergency departments for mild traumatic brain injury (mTBI) (Crowe et al., 2009). Post-concussive symptoms (PCS) are a marker of mTBI and can be classified as physical (ex., headache, fatigue), cognitive (ex., confusion, poor concentration), or affective (ex., anxiety, sadness) symptoms. Numerous questionnaires exist to detect PCS in school-age children, adolescents, and adults, but none of these measures are valid in young children. Recent studies highlight unique manifestations of PCS in young children, such as stomachaches, increased dependence (ex., clinginess, whining), excessive crying and tantrums (Bernard et al, 2017, Suskauer et al., 2018). These studies suggest a need to evaluate early childhood PCS using developmentally appropriate concepts and measures.
Objective: This study sought to report empirical data on an observational PCS inventory for early childhood and to determine whether the tool can identify mTBI-specific patterns of PCS.
Methods: Children (n = 245, 0–5 years; M age at injury = 35.7, SD = 19.8 months) with mTBI, an orthopedic injury (OI), or typical development (TD) were recruited in the Emergency Departments of four tertiary, urban pediatric hospitals and in daycares. The Report of Early Childhood Traumatic Injury Observations & Symptoms (REACTIONS) documents 17 symptoms using items representing observable manifestations and was completed by parents retrospectively (T0: pre-injury), acutely (T1: 24–48 h), subacutely (T2: 7–14 days) and in the persistent phase (T3: 25–35 days) post-injury.
Results: There were significant increases between pre- and post-injury reporting of manifestations by caregivers of children with mTBI in the cognitive (p = 0.010), physical (p = < 0.001), and behavioral (p = < 0.001) domains. However, pre- and post-injury manifestations did not differ in the OI group in any domain (cognitive; p = 0.198; physical; p = 0.774; behavioral; p = 0.268). Parents of children with mTBI also reported more manifestations in the three domains (cognitive, physical, behavioral, respectively) at T1 and T2 compared to parents of OI (T1: Pcognitive = 0.001; Pphysical = < 0.001; Pbehavioral = 0.036 and T2: Pcognitive = < 0.001; Pphysical = < 0.001; Pbehavioral = 0.041) and TD (T1: Pcognitive = < 0.001; Pphysical = < 0.001; Pbehavioral = < 0.001 and T2: Pcognitive = < 0.001; Pphysical = < 0.001; Pbehavioral = < 0.001) children. Finally, across the three domains at T3, more manifestations were also reported by parents of children with mTBI when compared to parents of TD children (Pcognitive = 0.002; Pphysical = < 0.001; Pbehavioral = < 0.001) and for physical and behavioral manifestations of OI children (respectively, p = < 0.001; p = < 0.001).
Conclusions: The REACTIONS inventory shows injury-specific patterns of PCS, such that parents of children with mTBI consistently reported more manifestations of cognitive, physical, and behavioral symptoms when compared to both orthopedic injury and typically developing comparison groups. REACTIONS, therefore, show promise for documenting PCS in early childhood.
400 Health-related social needs and components of social competence in children with traumatic brain injury
Libby Darta, Angela Cicciaa
aCase Western Reserve University, Cleveland, USA
ABSTRACT
Objectives: To examine health-related social needs and areas of social, family functioning, and behavioral deficits for children with a history of traumatic brain injury (TBI).
Methods: This study is a mixed-methods, prospective cohort study without randomization. Demographic and injury-related factors were collected via caregiver-report. The Ohio State University Traumatic Brain Injury (TBI) Identification Method (OSU TBI-ID) was used to identify children with TBI. The NeuroQol Social Relations- Interactions with Peers and the Social and Communication Disorders Checklist (parent report) were used to measure social communication, and the Family Assessment Device (FAD) general functioning subscale short version was used to measure family functioning. A subsection of participants who indicated interest participated in an interview examining areas of met and unmet needs relative to the child’s health-related social needs, social skills, behavior, and family functioning. Data will be analyzed using linear regressions. Data from the interviews will be qualitatively analyzed for codes in three phases: 1) developing categories of information, or open coding; 2) interconnecting the categories, or axial coding; and 3) connecting the categories, or selective coding. An explanatory sequential design will be used, where the quantitative data is integrated with and explained by the qualitative data, to produce a more in-depth understanding of the results. Integration will involve explaining the results of the initial quantitative phrase by connecting or following up the quantitative phase with the qualitative phase.
Results: Recruitment is ongoing and results with updated data will be available at the time of the presentation.
Conclusions: It is hypothesized that children with TBI from families with more health-related social needs will have increased levels of parent-reported areas of deficit in social skills, child behavior, and family functioning compared to children with TBI from families with fewer health-related social needs. Investigating the impact of HRSNs on child outcomes following TBI will address gaps in care and identify necessary referrals to community services. The integration of quantitative and qualitative data analysis identified in this work will add to the growing body of knowledge related to social competence outcomes for school-age students with TBI.
401 Families’ self-reported challenges in daily life in the chronic stage of pediatric acquired brain injury
Nina Rohrer-Baumgartnera, Ingvil Laberg Holthea,b, Edel Jannecke Svendsena,c, Ida Borgena,d, Jens Egelandb,e, Shari L. Wadef,g, Cecilie Røed,h,i, Marianne Løvstada,b
aResearch Department, Sunnaas Rehabilitation Hospital, Nesodden, Norway, bDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, cDepartment of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway, dDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, eDepartment of Research, Vestfold Hospital Trust, Tønsberg, Norway, fDivision of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA, gDepartment of Pediatrics, University of Cincinnati College of Medicine & Cincinnati Children’s Hospital Medical Center, Cincinnati, USA, hCenter for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, iInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
ABSTRACT
Background: Children with pediatric acquired brain injury (pABI) do not systematically receive rehabilitation in the chronic stage. An individualized, family-centered approach to rehabilitation with a high level of patient involvement and a focus on daily life challenges is warranted. To achieve that, more knowledge about the pABI-related challenges in daily life of these children and those of their parents is needed.
Objectives: (1) To describe the main self-reported pABI-related challenges in daily life for children, their parents/guardians, ranked by severity. (2) To examine if there are significant differences between the functional domains and severities reported by children and parents/guardians, between mothers and fathers, between boys and girls, and between families with a child with TBI and those with children with other diagnoses. Furthermore, we will (3) correlate the severity of the main pABI-related daily challenges with information about the child and parents captured by questionnaires such as parental mental health, parenting self-efficacy, child brain injury symptoms, as well as time since insult.
Methods: Data will be derived from the baseline-assessment of approximately 170 individuals from 60 families who participate in the ongoing Child in Context Intervention (CICI) Study, a randomized controlled trial (RCT). Inclusion criteria for participating in the CICI study are: (i) children 6–16 years of age with a CT- or MRI-verified ABI diagnosis (or loss of consciousness post-insult and verified neurological symptoms in cases where MRI could not be administered), (ii) time since insult at least one year, (iii) the child is attending school regularly, (iv) has self- or parent-reported cognitive, emotional, behavioral and/or social difficulties that affect everyday functioning and/or participation, (v) the family is able to participate actively in goal-oriented work and (vi) speaks sufficiently Norwegian or English. In a semi-structured interview at baseline, participants were asked to name the three main pABI-related challenges in daily life and to rank them on a 5-point Likert scale. Areas were categorized in accordance with the International Classification of Functioning, Disability and Health (ICF). Inclusion of participants will be finalized in October 2022, and results from the full data set will be presented at the conference.
Conclusion: Detailed knowledge about prioritized, individual pABI-related challenges in daily life for families with a child with ABI in the chronic stage and their associations with parent-, child-, and insult characteristics will be presented and could help us to tailor more effective individualized rehabilitation in the future.
402 Comparing treatment approaches to promote inpatient rehabilitation effectiveness: phase 1 of the CARE4TBI study
Jennifer Bognera, Cynthia Beaulieua, Erinn Hadea
aOhio State University, Columbus, USA
ABSTRACT
Comparing Treatment Approaches to Promote Inpatient Rehabilitation Effectiveness for Traumatic Brain Injury (CARE4TBI) is a pragmatic, prospective, multicenter observational study. Fifteen TBI Model Systems (TBIMS) sites are participating, with the TBIMS National Data and Statistical Center serving as the data coordinating center. The project is funded by the National Institute of Neurological Disorders and Stroke, leveraging the infrastructure of the National Institute on Disability, Independent Living, and Rehabilitation Research’s TBI Model Systems National Database. Based on over ten years of preliminary studies, we are using advanced causal inference methods to study “real-life” rehabilitation, representing the most comprehensive investigation of rehabilitation intervention effectiveness possible to date, with findings having the potential to directly and immediately impact clinical practice. Our work is unfolding in two phases and organized around three Specific Aims. In the first (and current) phase, Aim 1 is to standardize electronic medical record (EMR) documentation of rehabilitation therapy across the 15 sites to allow valid extraction for research and clinical operations. We are improving the utility of EMR by transforming unformatted narratives and fields to standardized, structured, clinical data elements to capture variables associated with the complex process of both therapy delivery and patient-specific recovery from TBI. We will present the template created for either direct ingestion or adaptation by sites. Phase 2 will address Aims 2 and 3, which will (Aim 2) compare the effectiveness of well-defined rehabilitation approaches to improve community participation and functional independence of patients with TBI and (Aim 3) identify patient, provider, setting, and post-discharge factors that modify the effect of therapy on outcomes. Utilizing the data extracted from the EMR, we will compare the effectiveness of Contextualized Treatment and Advanced Therapy individually, and in combination, on community participation at one year (primary) and functional independence. Contextualized Treatment directly rehabilitates real-life functions (e.g. dressing, meal preparation), as opposed to Decontextualized Treatment which works to strengthen component skills presumed to underlie real-life activity without working directly on the real-life activity (e.g. arm strengthening drills). Advanced Therapy involves activities that in healthy individuals involve higher level cognitive functions and/or the ability to adapt to perturbation and a changing environment. Marginal structural models (MSM) will be used to support causal inference in comparing the rehabilitation approaches, and structural nested mean models (SNMs) will be used to evaluate time-varying patient, provider and session factors, as well as post-discharge factors, that may modify the effect of therapeutic approach. This presentation will present the product of Phase 1 (standardized EMR template), while informing the rehabilitation community of the project as a whole, including plans for Phase 2.
403 FASDcare: understanding the factors influencing caregiver burden among family caregivers of people with FASD in Ireland
Katy Tobina,b, Elizabeth McCarthya,b
aTrinity College Dublin, Dublin, Ireland, bGlobal Brain Health Institute, Trinity College Dublin, Ireland
ABSTRACT
Background: Prenatal alcohol exposure is the most common preventable cause of intellectual disability. Fetal Alcohol Spectrum Disorder (FASD) is a permanent brain injury affecting an estimated 4.7% of people in Ireland, the third highest rate globally. A majority of individuals with FASD are never diagnosed and they lack much needed support services. This study aimed to
• examine the core difficulties experienced by caregivers of people with FASD, the amount and type of support required, and how much of these needs are currently met.
• Identify the level of burden experienced by caregivers of people with FASD in Ireland.
Methods: Data were gathered from Nov 2021 – Jan 2022 through a cross sectional, anonymous online survey. The survey gathered quantitative and qualitative data on the experiences of caregivers, challenges faced, and pathways to diagnosis. The study sample was recruited through convenience sampling. Participants were parents/caregivers of a child or young person with FASD living on the island of Ireland. Caregiver burden was measured using the Zarit burden (ZBI-12) scale. Descriptive statistics present sample demographics and a summary of key variables. The drivers of caregiver burden are explored using t-tests and non-parametric comparison tests, where appropriate. A model of the factors influencing caregiver burden is estimated using multivariate regression.
Results: A total of 83 participants answered the survey. A large proportion of the sample are foster parents (n = 39, 48%) or adoptive parents (n = 26, 32%). Females represent 81% of the sample (n = 47). Caregivers experience high levels of burden (mean = 25.6, median = 26.5). Here we explore the factors influencing caregiver burden, including financial status, and availability of services and supports.
Conclusions: This is the first study to describe the experiences of, and the high levels of burden faced by caregivers of people with FASD in Ireland. It is hoped that these findings will be used to support service development for this underserved population.
405 Long-term follow-up of older adults with traumatic brain injury: preliminary results from the uppsala long-term outcome of traumatic brain injury study (U-LOTS)
Charlotta von Setha,b, Anders Lewéna,b, Marianne Lannsjöa, Per Enblada,b, Jan Lexellc
aDepartment of Medical Sciences, Uppsala University, Uppsala, Sweden, bUppsala University Hospital, Uppsala, Sweden, cDepartment of Health Sciences, Lund University, Lund, Sweden
ABSTRACT
Introduction: Epidemiological studies show an increasing occurrence of traumatic brain injury (TBI) among elderly people (60 years and older). Advances in neurointensive care have improved survival after TBI. Therefore, the need for knowledge of factors of importance for outcome among elderly with TBI is large. The Uppsala Long-term Outcome of Traumatic brain injury Study (U-LOTS) is a longitudinal cohort study of persons having sustained a TBI at the age of 60 years or older. U-LOTS aims to describe functioning, disability, health, well-being, lifestyle and personal and environmental factors 3 years or more after TBI among people 60 years or older.
Objectives: To present the initial results from U-LOTS with focus on overall outcome as assessed by the Glasgow Outcome Scale – Extended (GOS-E) and the Functional Independence Measure (FIM) and to investigate associations between injury severity and outcome 3 years or more after TBI.
Methods: The Uppsala Traumatic Brain Injury (UTBI) register (catchment area of approximately 2 million inhabitants) includes all persons that are admitted to the Neurointensive care unit at Uppsala University Hospital following a TBI. From the UTBI register we recruited persons aged 60 years and older when suffering a TBI between the years 2008 and 2018. Follow-up was conducted as a home visit after a minimum of three years post-injury. Injury severity was classified as mild (Glasgow Coma Scale (GCS) 13–15), moderate (GCS 9–12) or severe (GCS 3–8). At follow-up, we used a set of validated outcome measures and collected data with structured interviews based on a study-specific questionnaire. For the present study we assessed outcome with GOS-E and FIM motor and FIM cognitive. Data are presented as median and range, and relationships between variables were analyzed with Pearson’s or Spearman’s rank correlation coefficient.
Results: A total of 68 persons (22 females and 46 males) aged 68 [60–84] years at the time of TBI were included in the analysis (median 94 [38–166] months post injury). Injury severity was mild [N = 23], moderate [N = 35] and severe [N = 10] cases. Injury severity did not differ between men and women. At follow-up, the median GOS-E was 6 [4–7, IQR]. The median FIM motor was 86 [77–90, IQR] and FIM cognition 33 [27–35, IQR]. The correlation between injury severity and GOS-E was rho = −0.3 (p < 0.05), and the correlation between injury severity and FIM motor was r = −0.36 (p < 0.01) and FIM cognition was r = −0.5 (p < 0.001).
Conclusions: Overall, our data show that outcome after a TBI among people 60 years or older is not substantially different from younger people and confirm the relationship between injury severity and outcome. Further studies in the U-LOTS will investigate specific factors of importance for outcome after TBI among elderly persons.
406 Salivary brain-derived neurotrophic factor as a biomarker in concussed athletes
Haley Chizuka, Mohammad Haiderb, John Leddya,b, Barry Willera,c, Praveen Aranyd
aUniversity at Buffalo, Department of Rehabilitation Science, Buffalo, USA, bUniversity at Buffalo, Department of Orthopedics, Buffalo, USA, cUniversity at Buffalo, Department of Psychiatry, Buffalo, USA, dUniversity at Buffalo, Department of Oral Biology, Buffalo, USA
ABSTRACT
Objectives: Brain-Derived Neurotrophic Factor (BDNF) is a key known mediator of neuronal maintenance and response to injury. It has been hypothesized that BDNF in plasma or serum is a potential biomarker of sports-related concussion (SRC). However, studies examining BDNF in saliva have reported inconclusive results. This pilot study was aimed at developing an optimized workflow to analyze salivary BDNF in concussed athletes.
Methods: Athletes (n = 4, 25% male, 15.5 ± 1.91 yrs) with concussion diagnosed by a sports medicine physician provided blood and saliva samples diurnally. After analyzing the first samples, 10 additional athletes (50% male, 15.5 ± 0.83 yrs) with diagnosed concussion provided saliva samples diurnally. Total protein in all analytes was assessed using Bradford’s Assay (BCA, Pierce). Saliva samples were concentrated using a lyophilizer (Labconco). An Enzyme-Linked Immunosorbent Assay (ELISA) for BDNF (R&D systems) was used to assess samples in triplicates. Data was organized and analyzed in Excel.
Results: Total protein in saliva (1.36 ± 0.31 mg/mL) was found to be lower than plasma (2.76 ± 0.2 mg/mL), and serum (2.74 ± 0.15 mg/mL). Hence, saliva samples were lyophilized and resuspended in 3 times less volume to approximate serum/plasma samples from each individual in the initial collection. At a 3-fold concentration we observed no differences among the three analytes for BDNF levels (p > 0.05). This concentration step was then repeated with the secondary collection of saliva and BDNF was reliably found in all provided samples.
Conclusion: This pilot study suggests salivary BDNF concentration may be assessed for post-concussion monitoring in adolescent athletes, but that sample analysis methodologies are critical to producing conclusive BDNF data. Saliva offers a noninvasive and convenient analyte, with appropriate concentration, that is very attractive for diagnosis and surveillance post-concussion.
407 Prevalence of dizziness and vestibular dysfunction in patients with persistent post-concussion symptoms: a cross sectional study
Line Amalie Hellemosea, Jørgen Feldbæk Nielsea
aHammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Aarhus, Denmark
ABSTRACT
Background: Concussion, the mildest form of traumatic brain injuries, is an important public health concern. About 20% of patients with concussion experience persistent physical, emotional and emotional symptoms (PCS) longer than 3 months post-injury, which are associated with negative impact on labor market attachment, increased use of health care and increased need for social benefits. Dizziness is a frequently reported persistent symptom which can be very bothersome and extremely disabling for the individual patient, affecting both workability and quality of life. There is a lack of knowledge about the prevalence of dizziness in patients with persistent PCS and how frequently it is related to objective vestibular dysfunction.
Aim: We aim to investigate the prevalence of dizziness in a population of patients with persistent PCS. In addition, we aim to investigate whether these patients show objective signs of vestibular dysfunction.
Methods: A cross-sectional study is conducted on 100 patients (18–60 years) with persistent post-concussion symptoms 2–4 months after injury. Patients is consecutively recruited from general practitioners or emergency departments in Central Region of Demark as a part of an intervention study (ClinicalTrials.gov ID: NCT04798885). Inclusion of patients is current from May to November 2022.
The patients’ self-reported dizziness symptoms are measured through the Dizziness Handicap Inventory questionnaire and there was conducted an objective otoneurological examination of balance and vestibular function: Head Shake Test, Impuls test, test of the Vestibulo-occular reflex, Nystagmus-tests, Dix-Hallpikes test and Rhombergs’ test.
Results: In September 2022 we have included approximately 85 consecutive recruited patients in the study. Prevalence of self-reported dizziness, and descriptive results from the otoneurological examination of balance and vestibular function will be presented.
Perspectives: This study will provide knowledge about the prevalence of dizziness in a population of patients with persistent PCS. Furthermore, the study will contribute with knowledge about whether dizziness in persistent PCS may be related to injuries to the vestibular organ which may again inform future treatment for post-concussion dizziness. Knowledge about the etiology of post-concussion dizziness is important for us to develop treatment in the future.
408 Assessing and managing post traumatic amnesia: The INCOG 2.0 guidelines for traumatic brain injury
Jennie Ponsforda,b, Jessica Trevena-Petersa,b, Shannon Janzenc, Amber Harnettc, Shawn Marshalld, Eleni Patsakose, Ailene Kuae, Amanda McIntyrec, Robert Teasellc, Catherine Wiseman-Hakese,f, Diana Velikonjag,h, Mark Theodore Bayleye,i, Adam McKaya,b
aTurner Institute for Brain and Mental health, Monash University, Melbourne, Australia, bMonash Epworth Rehabilitation Research Center, Epworth Healthcare, Melbourne, Australia, cLawson Health Research Institute, Parkwood Institute, London, Canada, dThe Ottawa Hospital-Rehabilitation Center, University of Ottawa, Bruyere Research Institute, Ottawa, Canada, eKITE Research Institute, Toronto Rehabilitation Institute – University Health Network, Toronto, Canada, fSpeech Language Pathology Program, School of Rehabilitation Science, McMaster University, Hamilton, Canada, gAcquired Brain Injury Program, Hamilton Health Sciences, Hamilton, Canada, hDepartment of Psychiatry and Behavioral Neurosciences, DeGroote School of Medicine, McMaster University, Hamilton, Canada, iUniversity Health Network, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
Post-traumatic amnesia (PTA) is a common occurrence following moderate-to-severe traumatic brain injury (TBI) and emergence from coma. It is characterized by confusion, disorientation, retrograde and anterograde amnesia, poor attention and frequently, agitation. Clinicians and family need guidelines to support management practices during this phase. An international team of researchers and clinicians (known as INCOG) met to update the INCOG guidelines for assessment and management of PTA. Previous recommendations and audit criteria were updated based on review of the literature from 2014. Six management recommendations were made: one based on Level A evidence, two on Level B and three on Level C evidence. Since the first version of INCOG (2014) three recommendations were added; the remainder were modified. INCOG 2022 recommends that individuals should be assessed daily for PTA, using a validated tool (Westmead PTA Scale), until PTA resolution. To date, no cognitive or pharmacological treatments are known to reduce PTA duration. Agitation and confusion may be minimized by a variety of environmental adaptations including maintaining a quiet, safe and consistent environment. The use of neuroleptic medications and benzodiazepines for agitation should be minimized, and their impact on agitation and cognition monitored using standardized tools. Physical therapy and standardized activities of daily living (ADL) training using procedural and errorless learning principles can be effective, but delivery should be tailored to concurrent levels of cognition, agitation and fatigue. In conclusion, stronger recommendations regarding assessment of PTA duration and effectiveness of ADL training have been made. Evidence regarding optimal pharmacological and non-pharmacological management of confusion and agitation during PTA remains limited, with further research needed. These guidelines aim to enhance evidence-based care and maximize consistency of PTA management.
409 Associations between personality traits and health-related quality of life after mild-to-moderate traumatic brain injury
Silje Christine Reistad Furea, Benedikte Madsena,b,c, Cecilie Røea,b,c, Marianne Løvstadd,e, Nada Andelica,b, Emilie Isager Howea
aDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, bResearch Center for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, University of Oslo, Oslo, Norway, cInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway, dDepartment of Research, Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway, eDepartment of Psychology, University of Oslo, Oslo, Norway
ABSTRACT
Background: Health-related quality of life (HRQoL) is an important outcome and is consistently reported as reduced after traumatic brain injury (TBI). This is often attributed to lingering symptoms after injury, which in turn is suggested to be influenced by personality traits. Still, the relationship between personality traits and HRQoL after TBI is scarcely explored.
Objective: To explore the association between personality traits and HRQoL 1 year after mild-to-moderate TBI.
Method: Included participants had suffered a mild-to-moderate TBI 8–12 weeks previously, were between 18–60 years of age, employed ≥ 50% at time of injury and sick listed ≥ 50% at time of inclusion due to post-concussion symptoms. The participants were originally included in a randomized controlled trial, but are analyzed as one cohort in this study as there were no differences between the interventions groups in HRQoL after 1 year. HRQoL was measured using the Quality of Life after Traumatic Brain Injury Overall scale (QOLIBRI-OS). Personality traits were determined using the NEO Five-Factor Inventory-3 (NEO-FFI-3) to map levels of the Big Five personality traits: Neuroticism, Extraversion, Openness to experience, Agreeableness and Conscientiousness. The global multivariable linear regression model also controlled for sociodemographic (age, sex, education, children in household) and injury-related factors (symptom burden at baseline assessed using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), presence of extracranial injuries, and injury severity).
Results: In total, 87 participants were included in the study. Mean age of the sample was 43 (SD 10) years, 52 (60%) were female, with mean education of 16 (SD 2) years, and 47 (54%) had child(-ren) living in the household. Average acute GCS was 15 (SD 1) and 41 (47%) suffered additional extracranial injuries. Total RPQ score at baseline was 28 (SD 11) in average, and mean QOLIBRI at 1 year was 62 (SD 22). The best-fitting model accounted for 35% of the variance in HRQoL 1 year after mild-to-moderate TBI. Neuroticism, Extraversion, Agreeableness and Conscientiousness remained in the best-fitting model, in addition to sex, having children in the household and symptom burden at baseline. Symptom burden (coef −0.5, 95% CI −1.0 to −0.1, p = 0.02), Neuroticism (coef −0.6, 95% CI −1.1 to −0.1, p < 0.04), and Conscientiousness (coef −0.8, 95% CI −1.4 to −0.2, p < 0.02) were significantly and negatively associated with HRQoL, whereas Extraversion (coef 0.4, 95% CI 0.1 to 0.9, p < 0.05) was positively associated.
Conclusion: Lower symptom burden, levels of Neuroticism and Conscientiousness, as well as higher levels of Extraversion, were related to better HRQoL 1 year after injury. This highlights the importance of considering the patients’ personality traits, in addition to symptom burden, in follow-up and treatment after mild-to-moderate TBI.
410 Impact of service user-files and collaborative rehabilitation planning in a community brain injury rehabilitation service: a pilot study
Eunan McCruddena
aBelfast HSC Trust, Belfast, United Kingdom
ABSTRACT
Background: Rehabilitation following brain injury requires collaboration between the person injured, significant persons in the rehabilitative environment (whether family or carers) and supporting services. In order to ensure maximal benefit it is essential that all parties hold a shared understanding of goals, priorities and strengths of all involved parties. Post-injury the language used to understand, describe and categorize post-brain injury deficits can differ significantly across those involved in the rehabilitative journey, leading to breakdown in recollections, communications and a lack of clear focus in terms of rehabilitation plans.
Aims: This pilot study sought to evaluate whether service-user held details of rehabilitative goals, plans and advice contributed to improved outcomes and experience of the rehabilitative journey.
Methods: A case-control design was employed to compare the experiences of service users undergoing community rehabilitation for brain injury related deficits. A two group design (N = 10) compared the experiences of a standard care (n = 5) and a group (n = 5) who held person-centered, bespoke rehabilitation files at home, which included details of their identified goals and multi-disciplinary recommended home-exercise and recovery programmes.
Results: Findings of the pilot will compare the groups on the basis of goal attainment, standardized assessment of rehabilitative involvement and patient-reported outcome measures (PROMs), including accessibility and acceptability of the alternate programmes of involvement.
Conclusions: Findings will be discussed with consideration of matters regarding governance and a service focus on providing timely, person-centered and need-focused rehabilitation. Consideration will also be given to how communication, cognitive, sensory and motor concerns are integrated into the delivery of person-centered rehabilitative services.
411 Audit of patients in disorders of consciousness (DoC) and implementation of a DoC pathway in a Scottish inpatient neurorehabilitation setting
Alasdair FitzGeralda, Blanca Povedaa, Emeritus Tom McMillanb
aNHS Lothian, Edinburgh, United Kingdom, bUniversity of Glasgow, Glasgow, United Kingdom
ABSTRACT
Prolonged Disorders of Consciousness (PDoC) can occur following Acquired Brain Injury (ABI). PDoC patients are complex in nature and benefit from specialist long term rehabilitation, assessment and review. Unfortunately, at present, it is difficult to capture the true prevalence rate of this population across the UK. This report aimed to audit the number of patients in a PDoC referred to a Scottish inpatient neurorehabilitation service and the impact of having a specialist PDoC pathway that aligned with the Royal College of Physicians recommendations. This audit also aimed to compare the outcomes and discharge destinations following neurorehabilitation of patients admitted in a disorder of consciousness following the development of this pathway (2016–2018) with those admitted over a similar time period prior to the onset of the new pathway (2013–2015).
The pathway described in this paper, has highlighted the benefits of a skilled and coordinated MDT, with professionals experienced in use of medication and assessment for PDoC. In particular, the present audit shows that when PDoC patients are ready for discharge from acute hospital, a clinical pathway that supports transfer to a neurorehabilitation hospital focusing on the assessment and rehabilitation of PDoC, improves destination outcome and the need for a gastrostomy. Patient trajectories were better after admission to the specialist PDoC neurorehabilitation pathway. Forty-eight percent of patients improved from VS to MCS or emerged from a DoC after the pathway was implemented, compared to 3% who were transferred to a hospital without a specialist pathway in the previous year. In addition, data gathered suggested there was also a trend toward reduced acute hospital stay.
The present audit also highlights some areas for development in Scotland in terms of service delivery, which include patient identification, level of expertise or training. Although the prevalence of PDoC is low, cases can be highly medically complex and require significant care input. Given the recent development of Major Trauma Centers, Scotland is in a prime position to make a significant change in the life and outcomes of these patients. It is vital that regional health boards consider what is currently offered for these patients, and that a National Standard for care of PDoC for Scotland is set to improve outcomes for these patients and so that they continue to receive the most fair and ethical service throughout their journey.
412 Associations of psychological resilience with brain structure and functional connectivity in pediatric concussion
Olivier Browna, Zhuo Fanga, Katherine Healeya,c, Roger Zemeka,b, Andra Smitha, Andrée-Anne Ledouxa,b,c
aUniversity Of Ottawa, Ottawa, Canada, bChildren’s Hospital of Eastern Ontario, Ottawa, Canada, cCarleton University, Ottawa, Canada
ABSTRACT
Background: Children and adolescents have among the highest rates of emergency department visits related to traumatic brain injury. Psychological resilience might be associated with functional connectivity and brain structure after sustaining a concussion.
Purpose: This work summarizes findings of associations between resilience with brain structure and functional connectivity in pediatric concussion.
Methods: Children with an acute concussion or orthopedic injury were recruited from an emergency department as part of a larger randomized controlled trial. All recruited participants were administered the Connor-Davidson Resilience Scale 10 (CD-RISC 10) and completed brain scanning on two occasions: 72 hrs and 4-weeks post-injury. Several analyses were conducted to investigate the associations between CD-RISC 10 scores and DTI metrics, namely fractional anisotropy (FA); mean diffusivity (MD); axial diffusivity (AD); and radial diffusivity (RD), as well as resting-state fMRI functional connectivity (FC) in the default mode, salience, and central executive networks. CD-RISC 10 scores were correlated with DTI metrics and with FC to seeds of the default mode, salience, and central executive networks.
Results: DTI analyses included 66 children with concussion (median[IQR] age = 12.88[11.82–14.35]; 47% female) and 29 children with orthopedic injury (median[IQR] age = 12.49 [11.18–14.00]; 41% female). fMRI analyses included 69 children with a concussion (median age[IQR] = 12.81 [11.79–14.36]; 46% female) and 30 children with an orthopedic injury (median age[IQR] = 12.27[11.19–13.94]; 40% female). Resilience at 72 hrs was significantly related to the DTI metrics at 72 hrs, including FA, MD, and RD, in the concussion group. These associations were identified along the forceps minor, superior longitudinal fasciculus, anterior thalamic radiation. DTI analyses also identified significant associations in the orthopedic group between resilience at 72 hrs and 4-week MD and RD measures in the forceps minor and superior longitudinal fasciculus. The fMRI analyses identified a significant association in the concussion group, whereby 72 hrs resilience was correlated with 72 hrs FC between the lateral occipital cortex and lateral prefrontal seed of the central executive network. fMRI analyses also identified significant associations in the orthopedic injury group, whereby resilience change scores were correlated with FC changes between the cerebellum and lateral parietal seed of the default mode network. This association was significantly moderated by group. Additional significant associations in the orthopedic injury group were identified, whereby 72 hrs resilience was correlated with 72 hrs FC between the posterior cingulate gyrus and the left anterior insula seed of the salience network.
Conclusions: These results suggest that acute resilience is associated with acute DTI metrics and resting-state FC in pediatric concussion. This study identifies functional connectivity and DTI as promising objective imaging biomarkers for future interventions which aim to increase resilience in the early phases following pediatric concussion.
413 Regional blood flow alterations and symptom presentation following pediatric concussion: a PedCARE+MRI substudy
Veronik Sicarda, Rachel Kardisha,b, Zhuo Fangc, Katherine Healeya,b, Andra Smithc, Greg O Crond, Nishard Abdeena, Keith Owen Yeatesf,g,h, Gary Goldfielda, Nick Reedh, Roger Zemeka,i, Andrée-Anne Ledouxa,j
aCHEO Research Institute, Ottawa, Canada, bDepartment of Neuroscience, Carleton University, Ottawa, Canada, cSchool of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Canada, dDepartment of Neurology, Stanford University, Stanford, USA, eDepartment of Psychology, University of Calgary, Calgary, USA, fAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, fHotchkiss Brain Institute, University of Calgary, Calgary, Canada, hDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, iDepartment of Pediatrics, University of Ottawa, Ottawa, Canada, jDepartment of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Canada
ABSTRACT
Introduction: The pathophysiology underpinning concussion recovery and symptom resolution is not fully understood. Emerging evidence suggests that advanced neuroimaging modalities such as arterial spin labeling (ASL) might have prognostic utility for pediatric concussions.
Objectives: 1) Examine brain perfusion changes, both globally and regionally, in concussed children compared to orthopedic injury (OI) controls at 72-hour and 4-week post-injury. 2) Investigate the association between brain perfusion and symptoms severity within concussed and OI participants at both timepoints. 3) Compare brain perfusion between symptomatic and asymptomatic concussed participants, and those with OI at both timepoints.
Methods: Adolescents aged 10–17.99 years presenting to the emergency department within 48 hours of either an acute concussion or OI were recruited for the study and underwent ASL MRI scans at 72-hour and 4-week post-injury to measure brain perfusion. Participants completed the Health and Behavior Inventory (HBI) and retrospective HBI at both timepoints to measure symptom severity. Symptomatic status at each visit was determined by reliable change z-scores.
Statistical Analyses: 1) An ANCOVA investigated the Group (Concussion vs. OI)*Time (72-hour, 4-week) interaction on perfusion, with post-hoc regions of interest (ROI) analyses performed in significant regions. 2) Multiple regressions investigated the association between HBI total score and adjusted perfusion at each timepoint, with post-hoc ROI analyses performed in regions showing significant HBI*Group interactions. 3) Whole-brain 1-way ANCOVAs examined differences in perfusion based on symptomatic status (symptomatic vs. asymptomatic) and OIs at each timepoints. Pairwise ANCOVAs were conducted if no group effects were found. All models were adjusted for head motion and average global gray matter. Thresholds were set as uncorrected p < 0.001 at the whole-brain level, and family-wise error (FWE) corrected p < 0.05 at the cluster level.
Results: The study included 70 concussed youths (Mage = 13.05 ± 2.02 years, 47% female) and 29 youths with an OI (Mage = 12.59 ± 1.97 years, 41% female). The concussion group showed greater adjusted perfusion in the right middle frontal and left angular gyri compared to the OI at both timepoints, but they demonstrated lower perfusion in left superior temporal, left middle frontal, right superior temporal, and bilateral gyrus gyri, and right fusiform. Group moderated the association between perfusion and HBI within the left precuneus and superior frontal gyrus at both timepoints. At 4-week, symptomatic concussion sub-group (n = 10) showed lower adjusted perfusion within the right cerebellum and lingual gyrus relative to the OI group. Moreover, at 4-week, asymptomatic concussion sub-group (n = 59) showed lower adjusted perfusion relative to the OI group within the left calcarine, but greater perfusion within the left medial orbitofrontal cortex, right middle frontal gyrus, and bilateral caudate.
Conclusions: The current findings suggest that symptoms may indirectly reflect the subtle changes in brain perfusion that occur following a concussion.
414 Developing a peer support group in a new Irish level 2 neurorehabilitation inpatient unit
Anne Kehoea
aPeamount Healthcare, Dublin, Ireland, bPeamount Healthcare, Dublin, Ireland
ABSTRACT
Introduction: Research has highlighted the importance of the appropriate peer and social supports in psychosocial adjustment and adaptation in neurological rehabilitation (Cutler et al., 2016). This study involved the design, development and evaluation of a Peer Support Group within a new Level 2 Inpatient Specialist Neurorehabilitation Service for adults aged between 18 to 65 in Community Healthcare Organization (CHO) 7 of the Irish Health Services Executive (HSE) serving the Dublin/Midlands Hospital Group (MHG). The Unit is a 12 bedded facility, opened in September 2020 in Peamount Healthcare, Dublin. Inpatient neurorehabilitation care is provided for adults who have experienced a range of sudden onset neurological conditions including traumatic and acquired brain injury along with other chronic progressive neurological conditions/disorders where a period of inpatient rehab is indicated. Patients receive Interdisciplinary (IDT) input from a wide range of professionals including Medical, Nursing, Physiotherapy, Occupational Therapy, Clinical Psychology, Medical Social Work, Dietician and Pharmacology.
Method: The group was designed by the Interdisciplinary Team (IDT) in response to patient feedback gathered via semi structured interview with current and past patients. Themes gathered at the planning stage included the need for community, connection and social support during their rehabilitation journey. Interdisciplinary collaboration was a principal ingredient in developing this group intervention. The group is open to all patients taking place weekly for 60 minutes and is co facilitated by social work and psychology. It allows patients a predictable weekly space to direct the content of the group and gain from peer support. The therapeutic model used draws from narrative therapy, trauma focused cognitive behavior therapy, solution focused therapy, is person centered and acceptance based. Speech and language therapists and occupational therapists join the group as needed to assist in communication and participation for patients.
Results: Attendance at the group has been good at an average of 70% of ward capacity each week. With permission from participants following each session, facilitators record key themes. An analysis of these themes over the first 12 months was conducted. Recurring themes include grief/loss, trauma, navigating the points of transition in the rehabilitation journey, adjustment, making meaning, changed role and identity, adjustment to physical, cognitive, psychological and social changes. Often highlighted were the challenges individuals face within their social and support networks, relationships, employment, social activities. Making meaning and adjustment themes were also common.
Outcomes: The peer support group has highlighted the need for awareness of the important role psychological and social issues play in navigating such life changing events. Outcome measures both qualitative and qualitative will be discussed.
415 Relationship between physical activity during the first 2 weeks of a concussion and brain perfusion at 4 weeks in adolescents: a PedCARE+MRI substudy
Veronik Sicarda, Zhuo Fangb, Katherine Healeya, Andra Smithb, Greg O Cronc, Keith Owen Yeatesd,e,f, Nick Reedg, Roger Zemeka,h, Andrée-Anne Ledouxa,i
aCHEO Research Institute, Ottawa, Canada, bSchool of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa, Canada, cDepartment Neurology, Stanford University, Stanford, USA, dDepartment of Psychology, University of Calgary, Calgary, Canada, eAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, fHotchkiss Brain Institute, University of Calgary, Calgary, Canada, gDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, hDepartment of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada, iDepartment of Pediatrics, University of Ottawa, Ottawa, Canada, jDepartment of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Canada
ABSTRACT
Introduction: Protracted rest post-concussion may lead to prolonged recovery; cerebrovascular dysregulation and decreased gray matter perfusion are possible pathophysiological explanations.
Objectives: To examine 1) differences in brain perfusion between concussed and orthopedic injured (OI) youth at 4 weeks post-injury; and 2) the association between the amount of moderate-to-vigorous physical activity (MVPA) within the first 2 weeks of a pediatric concussion and brain perfusion at 4 weeks.
Methods: Children and adolescents aged 10–17.99 years with either a concussion or an OI were recruited from the emergency department within 48 hours of injury. The amount of MVPA within the concussion cohort was measured via a hip-worn accelerometer 24 hours/day for 14 consecutive days. Both groups underwent continuous arterial spin labeling magnetic resonance imaging at 4 weeks post-injury to assess brain perfusion. An ANCOVA was conducted to examine group differences in brain perfusion, adjusting for head motion and global average gray matter perfusion. For the concussion group, a general linear model investigated the association between MVPA within the first 2 weeks post-concussion and brain perfusion at 4 weeks, covarying for age, sex, head motion, and global average gray matter perfusion.
Results: The study included 70 participants with concussion (median[IQR] age = 12.70 [11.67,14.35] years, 47.1% females) and 29 with OI (age = 12.05[11.18,13.77], 41.4% females). Group differences in adjusted brain perfusion (concussion > OI) were observed within the left anterior cingulate cortex (ACC; pcluster-FWE = 0.001) and right middle frontal gyrus (rMFG; pcluster-FWE = 0.029). From the 70 children with a concussion, 52 children had valid accelerometer data, defined herein as 10 hours/day for 4 days [mean(SD) MVPA = 30.26(18.41) min/day]. Whole-brain analysis revealed a greater amount of MVPA was associated with lower adjusted perfusion within the precuneus (pcluster-FDR = 0.046). No significant associations were found between MVPA and adjusted brain perfusion in the ACC or rMFG.
Conclusions: These findings indicate differential brain perfusion profiles at 4 weeks post-injury between concussion and OI. Moreover, this study provides evidence that early physical activity following a pediatric concussion is associated with reduced perfusion in certain brain areas. Future studies are needed to determine whether perfusion alterations post-concussion are associated with clinical presentation and how MVPA may facilitate concussion recovery.
416 Understanding of traumatic brain injury in police custody suites in England and Wales
Gemma Bucklanda, Karene Taylora
aUK Acquired Brain Injury Forum (UKABIF), London, United Kingdom
ABSTRACT
Introduction: The UK Government has committed to improving awareness, understanding, and training on neurodiversity across the criminal justice system in England and Wales. Of all neurodiverse needs, dealing effectively with acquired brain injury (ABI) is especially important due to its high prevalence and the impact it can have on violence and suicidality. Both those affected and criminal justice practitioners can find ABI challenging to manage as it can hinder capacity to engage effectively with agencies, including the police. In 2021 and 2022, the UK Acquired Brain Injury Forum (UKABIF) conducted research which aimed to raise awareness and improve outcomes for young adults aged 17–25 who have ABI and are involved in the early stages of the criminal justice system. The research was funded by the Barrow Cadbury Trust under its young adult programme.
Method: UKABIF made requests to all police forces in England and Wales under the Freedom of Information Act 2000 about how ABI is understood and dealt with in police custody suites. 15 questions were asked which focused on screening for ABI and other neurodiverse conditions, the prevalence of ABI amongst those screened, particularly amongst young adults, what approaches were taken toward those identified, and the nature of training on ABI.
Results: Of the 44 forces who responded and were able to provide information, 10 did not have screening, training, or identified pathways for detainees with ABI. Few forces are explicitly looking for historic acquired brain injury – which is often hidden – in risk and healthcare assessments. For example, two areas had a specific screening tool in place and one had a risk assessment which explicitly addressed ABI. In other areas, ABI might be picked up should the person detained mention it or professionals see obvious presentation of brain injury. Only one force was able to provide statistics on prevalence of ABI picked up in risk assessments. 27 areas had received some training but this was mostly limited to first aid for recently acquired head trauma or more well-known neurodiverse conditions such as ADHD and autism.
Implications: While recent government interest in neurodiversity in the CJS in England and Wales is welcome, the research illustrates the scale of change required to recognize the impact of ABI on people in police custody. For example, training initiatives for the police, custody healthcare practitioners, and liaison and diversion services must include awareness of ABI alongside other neurodiverse needs such as ADHD and autism. Health services and the police should also work together to ensure that a history of ABI is picked up in police custody by these practitioners. In addition, health and police commissioners should develop and fund clear pathways for people with ABI who come into contact with the police.
417 Building a consumer-focused acquired brain injury research program
Simonne Collinsa,b, Louise Crowea,c,d, Sarah Knighta,c,d, Taylor Jenkina, Vicki Andersona,c,d
aMurdoch Children’s Research Institute, Parkville, Australia, bTurner Institute for Brain and Mental Health, Clayton, Australia, cThe Royal Children’s Hospital, Parkville, Australia, dUniversity of Melbourne, Parkville, Australia
ABSTRACT
There is increasing awareness of the value and need for consumer involvement in every step of the research pipeline, and funding bodies demand evidence of consumer involvement in grant applications. But how can we start collaborating with consumers if we are not already? And who are our consumers? Within the context of pediatric acquired brain injury (ABI), the Murdoch Children’s Research Institute (MCRI) has begun to address these questions through establishing an ABI Flagship research program. The Flagship unites all researchers at MCRI that work in the area of pediatric ABI (including, but not limited to, traumatic brain injury, concussion, stroke, cancer, demyelinating disorders), as well as clinicians from the Royal Children’s Hospital Melbourne who are on the frontline providing acute care for children and adolescents with ABIs. Together, our researchers and clinicians have charted a path forward to ensure that we are engaging in best practice consumer involvement by identifying who our consumers are and working in partnership with key not-for-profit organizations and government departments. Our large, collaborative team are poised to solve the pressing challenges faced by survivors of pediatric ABI and their families, thereby potentially reducing burden on public health systems, and supporting advocacy for public policy changes. This presentation will showcase our experiences in establishing an ABI Flagship, our current research focus, and how we design consumer-focused research projects.
418 Facebook use by adults with TBI: a think-aloud study
Reihaneh Ahmadic, Hajin Limd, Bilge Mutlua, Melissa Duffb, Lyn Turkstrac
aUniversity of Wisconsin-Madison, Madison, USA, bVanderbilt University, Nashville, USA, cMcMaster University, Hamilton, Canada, dSeoul National University, Seoul, South Korea
ABSTRACT
In this study, we elicited feedback on social media use from adults with traumatic brain injury (TBI), using a Think-Aloud method while participants accessed their social media accounts. The purpose was to understand how social media functions for users with TBI, relative to a framework proposed by Meshi, Tamir, and Heekeren (2015) to classify adults’ motives for using social media. The study was part of the Social Building Blocks Online (SBBS-O) project. The long-term aim of SBBS-O is to develop technology to alleviate social media accessibility barriers and challenges for individuals with TBI, so they have the same opportunity as their uninjured peers to enjoy the social and health benefits of social media participation. Emerging evidence has identified barriers and challenges, but studies were largely based on retrospective reflection or analysis of content posted in the past. The Think-Aloud method provided a window into real-time experiences of users with TBI.
We invited 8 adults with TBI to log in to their own Facebook page and use it as they regularly would, while narrating their experience (i.e., “thinking aloud”). Their comments were recorded and transcribed for qualitative analysis. We first analyzed participants’ utterances using the Meshi et al. framework to identify Facebook functions, which included: 1) broadcasting information, including words and images that are personal or shared from others; 2) observing others’ broadcasts; 3) giving feedback on others’ broadcasts, e.g., via “liking” posts; 4) receiving feedback on broadcasted information; and 5) engaging in social comparison. We then used an open coding method to understand the challenges participants faced while using Facebook. In other words, we examined both users’ needs for using Facebook, and Facebook features that made it challenging for users to meet those needs.
Participants used all categories of codes in the Meshi et al. framework. The a priori coding also revealed two dimensions that characterized participants’ Facebook use: whether they were active or passive about posting and self-disclosure on Facebook; and familiarity and fluency in using Facebook. Open-coding analysis revealed six major types of challenges: difficulty with language production and interpretation, attention and information overload, negativity and emotional contagion, insufficient guidance to use Facebook, online scams and frauds, and general accessibility concerns.
Participants with TBI used Facebook for the same reasons typical adults do, suggesting that social media can help increase social communication and reduce isolation and loneliness for those with TBI as well as it does for their uninjured peers. Participants identified significant barriers, supporting the need for modifications that could improve access for individuals with brain injury.
419 Use of smartphones and tablets after acquired brain injury to support cognition
Simon Beaulieu-Bonneaua,b, Laurie Duboisa,b, Bénédicte Dussaulta,b, Karine Lafleurc, Marie-Christine Ouelleta,b, Valérie Poulinb,c, Laura Monettaa,b, Krista Besta,b, Carolina Bottarid, Nathalie Bierd, Hannah Gulloe
aUniversité Laval, Québec, Canada, bCentre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada, cUniversité du Québec à Trois-Rivières, Trois-Rivières, Canada, dUniversité de Montréal, Montréal, Canada, eUniversity of Queensland, Brisbane, Australia
ABSTRACT
Objectives: This study aimed (1) to describe the patterns of use of smartphones and tablets in adults with acquired brain injury (ABI), from the perspectives of injured individuals and significant others, (2) to examine factors associated with mobile device use for cognition, and (3) to explore facilitators and barriers for supporting adults with ABI, from the perspective of rehabilitation clinicians.
Methods: A multimethod design was used, consisting of a quantitative cross-sectional study with individuals with ABI and significant others, and qualitative focus groups with rehabilitation clinicians. Data collection took place in Québec, QC, Canada. Participants were 50 adults with moderate or severe traumatic brain injury (n = 25) or stroke (n = 25) (42% women; mean of 50.7 years old and 4.6 years post-ABI), and 24 significant others. They completed a telephone survey on the use of mobile technology, a short cognitive screening tool, and self-reported measures of cognitive functioning and impact of technology use. Two focus groups were also conducted with 12 rehabilitation clinicians working with adults with ABI (4 occupational therapists, 3 neuropsychologists, 3 speech-language pathologists, 3 specialized educators). The discussion guide addressed the experience, facilitators, and barriers for supporting adults with ABI in using smartphones and tablets for cognition.
Results: Of the 50 individuals with ABI, 90% owned a smartphone or tablet. Of those, 31% reported difficulties in using their device post-injury, 44% had received support (mostly from significant others), and 46% were interested in receiving further personalized training to optimize their use. Mobile device use for cognition was common (64% of participants), and correlated with younger age, lower subjective memory and executive functioning, greater use of memory strategies, and more positive impact of technology. Significant others reported motor or visual impairments and feeling of dependency as barriers for mobile device use, and 65% mentioned that their injured relatives needed additional support that they were unable to provide. Thematic content analysis of the focus groups with rehabilitation clinicians revealed five areas of need to support individuals with ABI in using mobile devices for cognition: long-term follow-up, training in information technology, access to appropriate resources, up-to-date information on available technologies, and commitment from and interaction with significant others of people with ABI. All these areas of need, except the latter, are generally unmet in current clinical practice.
Conclusions: Using mobile devices for cognition is common post-ABI, and associated with the use of other, non-technological cognitive strategies. However, a significant proportion of individuals requires long-term support and training. Significant others and rehabilitation clinicians face several challenges and barriers in providing this support. The development of tailored training approaches may help to support people with ABI in using mobile devices for cognition.
420 Using activity trackers and a video conferencing platform to explore the impact of a 6-week outdoor walking-group program for adults with moderate-to-severe traumatic brain injury during COVID-19
Enrico Quilicoa,b,c, Shawn Wilkinsonb, Shane Sweetb,d, Lindsay Duncand, Christophe Alarieb,e, Evelyne Bédardd, Ioana Ghetaa, Catherine Brodeura, Angela Colantonioa, Bonnie Swainea,e
aRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, bCentre de recherche interdisciplinaire en réadaptation du Montréal métropolitain, Montréal, Canada, cApplied Human Sciences, Concordia University, Montréal, Canada, dKinesiology and Physical Education, McGill University, Montréal, Canada, eÉcole de réadaptation, Université de Montréal, Montréal, Canada
ABSTRACT
Introduction: Physical activity (PA) participation after moderate-to-severe traumatic brain injury (TBI) is challenging due to elevated PA barriers and the COVID-19 pandemic, which closed many community fitness center, including one offering an exercise program to adults with moderate-to-severe TBI. Therefore, we adapted the program to provide COVID-19 friendly PA through outdoor walking-groups, which previously showed potential with reported biopsychosocial benefits.
Objectives: The objectives of this study were to examine the use of activity trackers and video conferencing to explore the health-related impacts of the 6-week outdoor walking-group program for adults with moderate-to-severe TBI during COVID-19.
Methods: This pre-post exploratory study was carried out over the fall 2021 in an outdoor setting with telehealth supports. A convenience sample of 15 adults (8 men; 7 women) with moderate-to-severe TBI aged 21–61 years (M = 40.6, SD = 10.9) living in the community completed the intervention which followed a progressive approach to increasing number of steps by time, with periods of rest on two days per week (≤ 10% volume increase/week). Participants were instructed in the use of Fitbit activity trackers (over a Zoom video conferencing session) and wore Fitbit Inspire 2 devices to capture daily step counts. Exploratory outcomes included health-related pre- and post-intervention standardized questionnaires collected through a Zoom video conferencing platform (e.g., Positive and Negative Affect Schedule: Leisure Satisfaction Scale; Exercise Self-Esteem; Quality of Life after Brain Injury Scale). Descriptive statistics and paired t-tests were used for the analyses. RESULTS: Participant average weekly steps rose from 10011 steps per day to 11177 steps per day (12% increase). Three participants’ step count data were not included due to tremors and forgetting to wear the device (≥ 9 days). A major internet connectivity problem forced one telehealth session for Fitbit instructions to be carried out over the phone. Minor connectivity problems across the 59 other video conferencing meetings included internet (12%), audio (25%), and visual (36%) problems. Positive Affect (change = − 1.40 ± 8.40; t = − 0.65; p = 0.592); Negative Affect (change = 6.40 ± 6.41; t = 3.87; p = 0.002); Exercise Self-Esteem (change = 2.33 ± 5.72; t = 1.58; p = 0.136); Leisure Satisfaction (change = 0.13 ± 0.49; t = 1.04; p = 0.316); Quality of Life (change = − 1.72 ± 8.95; t = − 7.4; p = 0.472).
Conclusions: Activity trackers and a video conferencing platform were shown to be feasible to use, monitor daily steps, and explore the impact of an adapted PA program for adults with moderate-to-severe TBI. A 6-week outdoor walking-group intervention may lead to significant reductions in negative affect for adults with moderate-to-severe TBI, but future studies with larger samples and greater power are needed to validate these findings.
421 Subjective cognitive functioning in the first four years after mild to severe traumatic brain injury
Simon Beaulieu-Bonneaua,b, Eléonore Sarazina,b, Marie-Christine Ouelleta,b
aUniversité Laval, Québec, Canada, bCentre interdisciplinaire de recherche en réadaptation et intégration sociale, Québec, Canada
ABSTRACT
Objectives: This study aimed to (1) document subjective cognitive functioning over the first four years after traumatic brain injury (TBI), across injury severity (mild vs moderate/severe, and (2) to describe trajectories of significant cognitive complaints over time, and sociodemographic and premorbid factors associated with trajectories.
Methods: This project is derived from a larger longitudinal cohort study on mental health after TBI. Participants were 222 adults aged 18 to 65 years old who were hospitalized after a mild, moderate, or severe TBI in a Level I trauma center in Québec or Montréal, QC, Canada (mean age = 41.4 ± 15.2 years; 28% women; 65% mild, 21% moderate, 13% severe TBI). They completed telephone interviews and self-report questionnaires 4, 8, 12, 24, 36, and 48 months post-TBI. The main outcome measure was the Medical Outcomes Study Cognitive Functioning Scale (MOS-COG), a self-report questionnaire documenting the frequency of difficulties with reasoning, concentration, confusion, forgetfulness, sustained attention, and reacting slowly. The total score is transformed into a 0–100 scale, higher scores suggesting better cognitive functioning. Significant cognitive complaints were defined as presenting a score below two standard deviations under the mean of the original validation sample (MOS-COG total score < 49.4, roughly corresponding to cognitive difficulties most or all of the time).
Results: In a repeated mixed model analysis with the continuous MOS-COG total score as dependent variable, the Time effect was not significant (suggesting stable level of subjective cognition over time), and the TBI Severity effect was not significant (suggesting similar subjective cognition across injury severity levels). Among participants who completed at least three of the six assessments (n = 54/222), four trajectories were identified, including two stable trajectories: (1) with significant cognitive complaints at all assessments (n = 14; 9%), or (2) at none of the assessments (n = 81; 53%); and two unstable trajectories (i.e., with significant cognitive complaints at some but not all assessments): (3) with significant complaints at the first assessment (n = 25; 16%), and (4) without significant complaints at the first assessment (n = 34; 22%). There was a significant difference between trajectories on premorbid psychiatric history: the stable trajectory with significant cognitive complaints at none of the assessments had a lower pre-TBI rate of major depression (9%) compared to the other three trajectories (21–36%; p = 0.01). Trajectories did not differ on sex, age, TBI severity, or premorbid occupation status.
Conclusions: Surprisingly, self-reported cognitive functioning as measured by the MOS-COG did not differ across TBI severity levels, nor over time. Other factors that may play a role in subjective cognitive complaints include psychiatric symptoms and disorders, and self-awareness, which was not considered in this study. Future studies should investigate how these variables, as well as physical and occupational functioning, covary over time after TBI.
423 Electrical brain responses during visualization of positively-valenced videos featuring acquaintances or strangers. preliminary study in a healthy subject, an individual in minimally conscious state, and an individual with unresponsive wakefulness syndrome
Anny Mazaa, María Dolores Navarrob, Joan Ferrib, Enrique Noéb, Roberto Llorensa
aNeurorehabilitation and Brain Research Group, Universitat Politècnica de València, Valencia, España, bIRENEA. Instituto de Rehabilitación Neurológica, Fundación Vithas, Valencia, Spain
ABSTRACT
Introduction: Individuals diagnosed with disorders of consciousness after a brain injury represent a huge diagnostic challenge. Recent findings suggest that complementing bedside assessment of the neurobehavioral condition with neurophysiological sensing and emotionally valenced meaningful stimuli might contribute to improve diagnosis. This preliminary study investigates the effects of passive stimulation with positively-valenced videos featuring acquaintances or strangers on the electrical brain activity of one healthy subject, one subject in minimally conscious state (MCS), and one subject with unresponsive wakefulness syndrome (UWS).
Methods: A 24 55-second block paradigm alternating stimulation blocks, where participants visualized videos of a person (either an acquaintance or a stranger) talking to the camera, and resting blocks, where participants visualized a black screen with a white cross, was conducted. The stimuli included 6 videos of an acquaintance of the participants (a relative or friend) and 6 videos of a sex- and age-matched stranger describing positive experiences and traits either of the participants or other person, respectively. Brain activity was recorded using a 32-ch EEG headset. Both differential entropy and event-related synchronization/desynchronization were calculated for all frequency bands and electrodes. Artificial neural networks were trained for each participant to identify differences in their brain activity during visualization of acquaintances or strangers. Three different approaches were conducted differentiating and combining both differential entropy and event-related synchronization/desynchronization parameters.
Results: Classifiers trained using information of differential entropy showed mean accuracies of 78.2%, 78.1%, and 43.97% for the healthy participant, the participant in a MCS, and the participant with a UWS, respectively. Models trained considering only information of event-related synchronization/desynchronization showed mean accuracies of 60.6%, 51%. and 49.1% for these participants in the same order. Finally, classifiers trained using combined information of differential entropy and event-related synchronization/desynchronization showed accuracies of 71.7%, 61.7%. and 44.3%, respectively.
Conclusions: The performance of the artificial neural networks was consistent with the neurobehavioral condition of the participants, as worse accuracy of the classification models was associated to worse neurobehavioral condition, independent of the information taken into account by the models. Additionally, models that only considered differential entropy showed the best performance, showing remarkably higher accuracy than those based on event-related synchronization/desynchronization. The diagnostic paradigm used in this study could be a promising examination of the neurobehavioral condition that might complement diagnosis of disorders of consciousness and should be further explored in future studies.
Acknowledgments: This study was supported by the Conselleria d’Innovació, Universitats, Ciència i Societat Digital of Generalitat Valenciana (CIDEXG/2022/15).
424 Predictors for light sensitivity two months after mild traumatic brain injury
Eirik Vikanea, Kaia Frøylanda, Eline Aase Kordta, Charlotte Bjørnstada, Eike Wehlinga
aDepartment of Physical Medicine and Rehabilitation, Haukeland University Hospital, Raadal, Norway
ABSTRACT
The overall prognosis is good after a mild traumatic brain injury (mTBI) but between 5% and 20% develops post-concussion symptoms (PCS) where light sensitivity are the most common symptom after headache. In the present literature, there is a debate whether PCS result from psychological factors, organic brain injury or both.
Objective: To predict light sensitivity two months after mTBI.
Method: A prospective cohort study including 162 patients with mTBI, age 16–58, consecutively included at an outpatient clinic at Haukeland University Hospital, Norway. Demographic data and information about sick leave were collected from national registries. Injury characteristics were collected from medical records. Information about earlier disease and symptom profiles where obtained from self-report questionnaires. Light sensitivity from the Rivermead Post-concussion Questionnaire was used as the dependent variable in a stepwise linear regression analysis. Pre-, post- and injury-related factors were examined as potential predictors for light sensitivity.
Results: The final model indicated that light sensitivity was predicted by earlier head injury, pre-injury sick leave due to musculoskeletal disorder and self-reported anxiety and depression at HADS two months post-injury. Injury-characteristics like intracranial injury, location of brain injury, post-traumatic amnesia or severity at Glasgow Coma Scale did not become significant.
Conclusion: Patients with earlier head injury, earlier sick-listed and self-reported anxiety or depression post-injury are at risk to develop a light sensitivity after mTBI. Consequences of PCS including light sensitivity may reduce social activities, participation and ultimately quality of life. These findings strongly suggest a biopsychosocial approach in the treatment of patients with mTBI.
425 Searching for the just-right support for the design of smart-home technologies
Carolina Bottaria,b, Armel Ayimdji Tekemetieuc, Nathalie Biera,d, Guylaine Le Dorzea,e, Stéphanie Boulé-Rileya,b, Guillaume Paquettea,b, Mélanie Couturef,g, Hélène Pigotc,h, Sylvain Girouxc,h
aÉcole de réadaptation, Université de Montréal, Montréal, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montréal, Canada, cDomus Laboratory, Université de Sherbrooke, Sherbrooke, Canada, dCentre de recherche de l’Institut Universitaire de Gériatrie de Montréal (CRIUGM), Montréal, Canada, eÉcole d’orthophonie et d’audiologie, Université de Montréal, Montréal, Canada, fCentre for Research and Expertise in Social Gerontology (CREGÉS), Montréal, Canada, gDepartment of psychology, Université de Sherbrooke, Sherbrooke, Canada, hCentre de Recherche sur le Vieillissement, Sherbrooke, Canada
ABSTRACT
Introduction: People with a moderate to severe traumatic brain injury (TBI) frequently require cognitive assistance to engage in complex activities like meal preparation. Nonetheless, little is known about how to provide cognitive assistance in a manner that allows the person to overcome difficulties, progress and accomplish such a task, without thinking for them. Considering that individuals with TBI may still require cognitive assistance years after rehabilitation, innovative interventions such as smart-home technologies could be an alternative to family-provided assistance. This study aimed to identify the types of cognitive assistance provided within a minimally structured evaluation of everyday activities that supports precisely the person with respect to observed difficulties in a “just-right” manner, i.e., only the minimal level and only when one needs assistance to progress. Also, we aimed to grade the assistance types in order to eventually integrate them in a smart-home technology.
Methods: A mixed method study using video analysis was conducted. Forty-five people with moderate and severe TBI were assessed by one of three trained occupational therapists using the Instrumental Activities of Daily Living (IADL) Profile. Assessments were carried out in homes and surrounding environments, with minimal assistance provided to formulate goals, plan, carry out, and verify goal attainment. A qualitative analysis of the videos was completed to define the types of cognitive assistance observed and identify the most prevalent task-related difficulties and related assistance types. Finally, identified assistance types were graded based on the speech act theory to enable an innovative technology to progressively vary the amount of information given during an automated assistance.
Results: Nine types of cognitive assistance and one type of motivational assistance were identified and described when the participants with TBI formulated the goal of grocery shopping, planned a meal and carried it out safely. The two most frequent types of cognitive assistance were “stimulating thought processes,” which was implicit and indirect in nature, and “cueing,” which was explicit and direct. These types of assistances represented the top and bottom of the proposed gradation of cognitive assistance. Other types of cognitive assistance included “recalling a task element” and “reactivating a memory or knowledge,” both indirect and explicit. Motivational assistance, a category distinct from cognitive assistance, was also frequently used throughout to encourage participants to decide what to do and to do all they could without help.
Conclusion This study identified and graded various types of cognitive and motivational assistance that were provided to support individuals with TBI during meal preparation. Using this knowledge, smart-home technologies could be designed to provide them personnalised, “just-right” assistance that enhance their independence in complex everyday tasks. Further research is however needed to explore the extent to which these current results can be operationalized within an innovative technology.
427 Supporting decisions in an irish tertiary neurorehabilitation service: a human rights approach
Sarah Caseya, Phil Butlera
aNational Rehabilitation University Hospital, Dun Laoghaire, Ireland
ABSTRACT
There has been a paradigm shift in the provision of health and social care for those with disabilities, toward a human rights approach across all domains of care. In Ireland, a human rights-based approach to healthcare is reflected in healthcare policy and national standards and guidance to ensure quality healthcare provision that ensures fairness, respect, equality, dignity, and autonomy. Ireland is to the fore in developing progressive legislation to support this approach with the Assisted Decision-Making (Capacity) Act (ADMA, 2015). The ADMA affords individuals with disabilities greater agency, choice, and control over decision-making, with different levels of decision-making supports provided for where difficulty is encountered in the decision-making process. At the National Rehabilitation University Hospital (NRH) we have a long tradition of supporting autonomy, agency, and choice for our patients, assisting them to participate in decision-making about all aspects of their rehabilitation and discharge planning. In this poster, we describe the steps we have taken at the NRH to prepare for the full commencement of the ADMA in November 2022. We describe the outcome of a staff survey designed to inspire reflection and to assess the current level of awareness of the ADMA. We outline how these data have been used to inform the development of a Quality Improvement Project, and we present our PDSA cycle for implementing and measuring changes that will enable our interdisciplinary teams to effectively support decision-making and undertake assessments of decision-making capacity if necessary. We also describe qualitative steps taken in relation to the development of operational processes to support effective implementation of the ADMA at the NRH, ensuring our position in the vanguard of rights-based, patient-centered care.
428 How can we explain quality of life levels after a cerebrovascular accident?
Alba Aza Hernándeza, María Fernández, Antonio Manuel Amor, José Luis Castillo, Miguel Ángel Verdugo
aUniversity Of Salamanca, Salamanca, Spain
ABSTRACT
Background/Aim: Cerebrovascular accident or stroke has become one of the main causes of death and disability in the world. Even in mild cases, the sequels are long-lasting or permanent, which produces significant changes in the life of the person and their families. Traditionally, health-related quality of life models has been used, omitting variables of interest in people who have suffered a stroke years ago (e.g., self-determination, rights). Therefore, the aim of this research is to analyze the predictive variables of quality of life levels following a multidimensional model such as that of Schalock and Verdugo (2002/2003).
Method: A longitudinal 1-year follow-up of 78 adults (59% men, mean age 60.7 years) who sustained a stroke in Spain some time ago (mean time 5,4 years). Socio-demographics (gender, age, educational level, relationship status, employment) and injury severity (degree of dependence, time since injury, cerebral location, comorbidity of health conditions) were recorded at baseline. The Social Support Questionnaire- 6 (SSQ-6), Connor-Davidson resilience scale (CD-RISC), Community Integration Questionnaire (CIQ) and Patient health questionnaire (PHQ-9) were assessed at baseline and 1-year follow-up. Also, self-reported quality of life was reported using the CAVIDACE scale. Possible predictors of quality of life levels were assessed with hierarchical regression analyses.
Results: At baseline, the mean SSQ-6 was 2 for number of social supports and 5 for satisfaction with them (low social support but moderate satisfaction), the mean CD-RISC was 64 (moderate resilience), the mean CIQ score was 9 (very reduced community integration), and the mean PHQ-9 8 (low depression). The mean CAVIDACE self-report score was 106 (37% reporting impaired HRQL), quite similar to the mean obtained at baseline (103). In the final multivariate regression model, dependency level (β − 0.557, p < 0.01) and depression (β − 0.507, p = <0.001) significantly predicted 1 year follow-up quality of life, explaining 47% (adjusted R2) of the variance in quality of life.
Conclusions: Although the quality of life after a stroke depends to a large extent on its severity, that is, on the resulting degree of dependency, the great importance of other factors such as levels of depression has been shown. It would be of great interest to analyze the different dimensions of the quality of life model separately, allowing optimization of the interventions carried out with this population and their families.
430 Impact of telehealth and hybrid service delivery upon comprehensive rehabilitation outcomes for military populations with traumatic brain injury
Jessica Conklina, Tracey Wallaceb, Katherine McCauleya, Jackie Breitensteina, Brick Johnstonea, Russell Gorea
aShepherd Center, Atlanta, USA
ABSTRACT
SHARE Military Initiative at Shepherd Center is a comprehensive rehabilitation program serving military veterans and service members with mild chronic to moderate/severe traumatic brain injury (TBI). Although the SHARE clinical program has traditionally offered all services in-person, the onset of the COVID-19 pandemic necessitated rapid expansion of telehealth and hybrid services. Funded by the Wounded Warrior Project, this observational retrospective study evaluated the clinical impact of telehealth and hybrid service delivery upon treatment outcomes during the peak of remote service delivery implementation. The study sample consisted of 40 SHARE participants, who completed their treatment program from April 2020 to July 2021. The sample was predominantly white (73%) and male (85%), with average age of 42 years (SD = 8.6 years, range 24–60 years). Military service history included Army (63%), Navy (20%), Marine Corp (15%), and Air Force (3%). Length of stay was variable, ranging from 1 to 185 days (average of 60 days). Average percent of telehealth sessions was 42% (SD = 33%, range 0–94%). Clinical measures were administered at program admission and discharge, including measures of cognitive screening, behavioral health, and physical and vestibular symptoms. Predictor variable selection for multiple linear regression modeling was determined a priori, based on results of analyses on a historical (2013–2019) cohort of 154 SHARE clients, to identify prominent demographic factors, injury characteristics, and presenting comorbidities most strongly associated with treatment outcome indicators (i.e., total and subscale scores of the Mayo-Portland Adaptability Inventory-4 [MPAI-4] at discharge). Regression models were then applied to the current study data, with the addition of percent of telehealth sessions as a predictor variable. Results indicated that of the predictor variables (age, cognitive screening performance [RBANS Update] at admission, severity of depression [PHQ-9] and PTSD symptoms [PCL-5] at admission, and percent of telehealth sessions), cognitive screening performance was the only significant predictor of MPAI-4 Total Score, as well as Ability and Participation subscale scores. Cognitive screening performance and PTSD symptomology were both significant predictors of the Adjustment subscale score. Percent telehealth participation was not a significant predictor in any regression model. Results showed no evidence of negative impact of remote service delivery upon treatment outcome indicators, and support the use of telehealth and hybrid rehabilitation services. Results suggested that clients benefitted from program participation, regardless of whether services were delivered in-person or remotely. Findings also highlighted the importance of cognitive and psychiatric factors in predicting response to intervention and post-treatment functioning. Ongoing prospective studies will expand upon these findings to identify interactions between provider specialty (i.e., medical vs. rehabilitation therapy vs. behavioral health) and treatment service modality, in order to enhance delivery of individualized care for military populations with TBI.
431 Structural magnetic resonance imaging correlates of functional motor improvement during rehabilitation in-stay in pediatric acquired brain injury
Erika Moltenia, Elena Berettab, Sebastien Ourselina, Sandra Strazzerb, Marc Modata
aKing’s College London, London, United Kingdom, bIRCCS E. Medea, Bosiso Parini, Italy
ABSTRACT
Structural Magnetic Resonance Imaging (sMRI) is a tool commonly used to assess Acquired Brain Injury (ABI). However, association between location and extent of brain lesions observed through sMRI and individuals’ potentiality for functional recovery has not been fully clarified yet, and especially in children. Similarly, Gross Motor Function Measure (GMFM-88) is widely used for motor assessment in functional rehabilitation. sMRI and GMFM were employed in a center for pediatric patients receiving intensive in-staying physiotherapy rehabilitation after ABI. Aim of the study was to assess the association between sMRI features and changes in gross motor functions, assessed through GMFM, in children during in-staying period. We prospectively examined data from a group of 150 consecutive pediatric patients with ABI. GMFM was administered at 3 timepoints: at admission, after complete delivery of the first set of intensive rehabilitation sessions, and at discharge. An sMRI visit was offered at admission to the rehabilitation program. Univariate statistics was conducted on GMFM outcome at discharge, adjusted for age at trauma and GMFM at admission, on sMRI features: brain atrophy, diffuse axonal injury or white matter hyperintensity, brainstem, cerebellar, and basal ganglia lesions, and hemispheric damage (frontal, motor, post-central, parietal, temporal-hippocampal, and occipital).
Mean age of patients was 4.7 years (SD = 3.2). Females were 69. Median GCS was 6. Mean days of coma were 69 (SD = 116). Fifty-one children had traumatic ABI, 32 encephalitis, 24 anoxia, 14 hemorrhagic stroke, 12 ischemic stroke, 6 tumor resection and 11 other etiologies. Total and average GMFM showed increase over the 3 timepoints.
One-way ANOVA showed significant effect of time for both Total GMFM (F = 67.8, p < 0.001) and Average GMFM (F = 67.4, p < 0.001). Analogously, all the 5 GMFM domains increased from timepoint 1 (admittance) to subsequent timepoints 2 and 3, until discharge. MANOVA confirmed the effect of time, overall (F = 13.8, p < 0.001) and for each domain of the scale. At admission, GMFM correlated with Level of Cognitive Functioning Scale (LOCFAS, rho = 0.55) and Glasgow Outcome Score (GOS, rho = 0.54), after correction for age and sex. At discharge, GMFM correlated with LOCFAS (rho = 0.40, p < 0.001) and GOS (rho = 0.49), motor damage (rho = 0.48), insurgence of epilepsy (rho = −0.55) and days of coma (rho = −0.68) (p < 0.001 for all correlations).
Analysis of sMRI revealed significant effects for brain atrophy (p-val = 0.0037) and occipital lesions (p-val = 0.0004). A borderline effect was also found for the presence of diffuse axonal injury or white matter hyperintensity (p-val = 0.0.0046), after correction for multiple tests (Bonferroni: 0.0045).
We conclude that a relation is observed between patients’ evolution (i.e., GMFM scores) and 1) initial location and extent of brain lesions, as per sMRI, and 2) severity and complication of disease, as indicated by correlations with days of coma and epilepsy, and initial neuropsychological scales such as LOCFAS.
432 Advanced brain aging after moderate-severe traumatic brain injury
Emily Dennisa, Alexander Olseng, Maheen Adamsonb, Talin Babikianc, Erin Biglera, James Colet, Kristen Dams-O’Connord, Ekaterina Dobryakovae, Helen Genovae, Jordan Grafmanf, Asta Habergf, Torgeir Hellstromw, Cooper Hodgesa, Andrei Irimiai, Ruchira Jhaj, Paula Johnsona, Vassilis Koliatsosk, Hannah Lindseya, Abigail Livnyl, Marianne Lovstadm, David Menonn, Abdalla Mohamedo, Martin Montip, Virginia Newcomben, Mary Newsomeq, Jennie Ponsfordr, David Sharps, Hanne Smevikg, Gershon Spitzr, Samantha Vervoordth, Lars Westlyeu, Ross Zafontev, Paul Thompsoni, David Tatea, Elisabeth Wildea, Frank Hillaryh
aUniversity of Utah, EMERALD HILLS, USA, bRehabilitation Department, VA Palo Alto, Palo Alto, USA, cDepartment of Psychiatry and Biobehavioral Sciences, UCLA School of Medicine, Los Angeles, USA, dDepartment of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, USA, eKessler Foundation, East Hanover, USA, fCognitive Neuroscience Laboratory, Shirley Ryan AbilityLab, Chicago, USA, gNorwegian University of Science and Technology, Trondheim, Norway, hDept of Psychology, Penn State University, State College, USA, iUniversity of Southern California, Los Angeles, USA, jUniversity of Pittsburgh, Pittsburgh, USA, kJohns Hopkins University School of Medicine, Baltimore, USA, lDivision of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Israel, mSunnaas Rehabilitation Hospital, Nesodden, Norway, nDivision of Anesthesia, University of Cambridge, Cambridge, United Kingdom, oThompson Institute, University of the Sunshine Coast, Birtinya, Australia, pDepartment of Psychology, UCLA, Los Angeles, USA, qBaylor College of Medicine, Houston, USA, rMonash University, Melbourne, Australia, sImperial College London, London, United Kingdom, tUniversity College London, London, United Kingdom, uDepartment of Psychology, University of Oslo, Oslo, Norway, vHarvard Medical School, Boston, USA, wOslo University Hospital, Oslo, Norway
ABSTRACT
Traumatic Brain Injury (TBI) can have lifelong impacts on brain health with longstanding evidence of brain atrophy after injury. We examine how prior neurotrauma influences brain morphology over the lifespan through collaborative mega-analysis in the ENIGMA Adult Moderate/Severe TBI working group by comparing predicted brain age with chronological age across a large, international sample. With our large sample size we aimed to examine whether TBI was associated with advanced or accelerated brain aging. Data come from 7 sites across 3 countries and include some multi-site projects. There was a total of 866 participants (546 TBI/320 comparison, 627 M/239 F, mean age = 47.8 years ± 18.2, age range = 18–85). Participants were scanned with a mean post-injury interval of 14.6 years ± 17.1 (range = 2 months-66 years). Brain age was estimated using BrainAgeR (https://github.com/james-cole/brainageR). Briefly, raw T1 scans were segmented using SPM12, normalized, and vectorized. Tissue segmentations were visually checked for quality. Principal components analysis (PCA) was run on a template, and components explaining 80% of the variance were retained. The rotation matrix from the template PCA was applied to our dataset. Participant components were compared to a training dataset (N = 3,377 from 7 datasets, age range 18–100), and brain age was predicted using the kernlab package in R. Predicted age was subtracted from chronological age to generate a predicted age difference (PAD), such that negative scores indicated younger-appearing brains. Group differences in PAD were estimated using a linear mixed effects model, with nested random effects to control for cohort and multiple sites within cohorts, covarying for chronological age. Consistent with prior work (see Cole et al., 2015) the TBI group had a significantly older brain age (b = 5.4 years, p = 1.1x10-10) and this difference was still significant when covarying for time since injury or excluding participants with visible brain lesions (p < 1x10-5). There was a significant interaction with gender but no association with patient age or race/ethnicity. We did not find evidence for accelerated aging. With brainage, we can examine factors that influence brain health after TBI using a metric that is robust to structural variations in disruption.
433 Development of a recommendation interface to personalize the assistance provided through a cognitive orthosis during meal preparation: a user-centered design
Carolina Bottaria,b, Marlène Gillesc, Sylvain Girouxd,e, Hélène Pigotd,e, Éric Maiselc, Pierre De Loorc, Nathalie Biera,f
aÉcole de réadaptation, Université De Montréal, Montréal, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Institut universitaire sur la réadaptation en déficience physique de Montréal du CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montréal, Canada, cLab-STICC (UMR 6285 CNRS), ENIB, Brest, France, dDomus Laboratory, Université de Sherbrooke, Sherbrooke, Canada, eCentre de Recherche sur le Vieillissement, Sherbrooke, Canada, fCentre de recherche de l’Institut Universitaire de Gériatrie de Montréal (CRIUGM), CIUSSS du Center-Sud-de-l’Île-de-Montréal, Montréal, Canada
ABSTRACT
Assistive technologies for cognition (ATC) are promising avenues to support individuals with traumatic brain injury (TBI) in complex daily activities like meal preparation. While meal preparation is essential for independent living, people with TBI may require many assistances to safely complete this task due to their cognitive deficits. To support these individuals, our team developed an ATC using smart-home technologies, the Cognitive Orthosis for coOKing (COOK). To date, COOK has been successfully implemented with five individuals living with cognitive deficits due to an acquired brain injury, all presenting various living contexts, difficulties and assistance needs. Considering the potential of this technology to support individuals with cognitive deficits in various contexts and the heterogeneity of profiles within this clientele, COOK should be easily configurable to the person’s needs by therapists. This study aimed to develop an interface that could recommend functionalities and assistances provided by COOK depending on the therapist’s evaluation. Using a user-centered design, experts in computer sciences and occupational therapy collaborated to develop a recommendation interface for therapists that will consider (1) the level of resemblance between the patients, (2) their living context, (3) their physical abilities, and (4) their cognitive abilities, especially in terms of executive functioning. An evaluation form that could be completed by therapists was developed using the initial assessments and initial configurations of COOK for the five participants who used COOK within their home. For each participant, observations that were identified by therapists as potentially having an impact on the configuration of COOK were noted and included in the evaluation form. Selected configurations for the five participants were also noted in relation to the evaluation form. Then, the form was completed and tested with fifteen assessments from previous studies using the Instrumental Activities of Daily Living (IADL) Profile, an observation-based evaluation that evaluates the level of independence of individuals in complex activities within their home and surroundings. Each assessment was reviewed using the scoring sheets completed in the previous studies, and discussed to identify how COOK could be configured according to their needs. Overall, 13 men and 7 women were included to develop the recommendation interface. They were in average aged 39 years old and were around 10 years post-TBI (1–32 years). During the IADL Profile, many had difficulty finding and choosing a meal to prepare, following a recipe and being safe around the stove. Recommendations to support them included providing a list of adapted recipes and ensuring safety with COOK. As a next step, the recommendation interface will be presented to occupational therapists to explore their perceptions on the recommendations proposed by the system and its usability. Such a recommendation interface would ultimately facilitate the configuration of COOK for future users, even inexperienced ones.
434 Evaluation of oculomotor functions as a diagnostic tool in concussions: a pilot study using fMRI
Ekaterina Lunkovaa, Alain Ptitoa,b,c, Rajeet Singh Salujaa,d
aMcgill University, Montreal, Canada, bMontreal Neurological Institute, Montral, Canada, cDepartment of Psychology, McGill University Health Center, Montreal, Canada, dMcGill University Health Center Research Institute, Montreal, Canada
ABSTRACT
Mild traumatic brain injury (mTBI), frequently referred to as concussion, is a major public health problem. Ambiguity still exists with regard to the pathophysiology and management of concussions, leaving an objective diagnosis a topical problem. Previous studies by our team demonstrated that fMRI is an objective approach that allows consistent, reproducible results in the diagnosis of concussion. However, given the limited availability of fMRI in a clinical setting, an alternative approach is needed. One of the often-reported pathologies in mTBI, is a deficit in oculomotor function. Due to the neuroanatomical overlap between eye-movement circuitry and mTBI pathophysiology, it is expected that visual deficits would follow mTBI. In this pilot study, we aim to investigate the possibility of using an automated tool for oculomotor assessment in the concussion diagnosis.
We carried out fMRI testing with 4 tasks using an automated eye-tracking system evaluating oculomotor functions: Smooth Pursuit (SP), Saccades, Anti-Saccades, and Optokinetic Nystagmus (OKN). 12 adult concussed subjects within 1-month post-injury and 12 age- and sex-matched healthy subjects were tested. The fMRI images were preprocessed and analyzed using SPM12, and BOLD signal alterations were compared between groups.
The results of a whole-brain analysis showed increase in BOLD signal in concussed group compared to healthy controls: in cingulate gyrus (BA 31, 32) bilaterally during Saccades, and in left middle occipital gyrus during Anti-Saccades. The results of ROI analysis showed significant differences only in Cuneus in SP. Results from the eye-tracking system didn’t show any significant differences between groups.
These preliminary results showed that concussed subjects demonstrate significant elevation in activation in brain areas involved in different aspects of oculomotor function as well as associated with activity during cognitive tasks (BA31 as a central node of the DMN), between the concussed group and the group of healthy controls. These results are encouraging, and they suggest that fMRI using described oculomotor tasks is a promising approach in the diagnosis of concussion.
References
1. Chen, J. K., Johnston, K. M., Collie, A., McCrory, P., & Ptito, A. (2007). A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. Journal of Neurology, Neurosurgery & Psychiatry, 78(11),1231–1238.
2. Rockswold, S. B., Burton, P. C., Chang, A., McNally, N., Grant, A., Rockswold, G. L., … & Lenglet, C. (2019). Functional magnetic resonance imaging and oculomotor dysfunction in mild traumatic brain injury. Journal of neurotrauma, 36(7),1099–1105.
435 Head injury and disability in adults undergoing pre-sentencing assessment by social work
Tom McMillana, Holly De Moraa, Jean McFarlanea
aUniversity of Glasgow, Glasgow, United Kingdom
ABSTRACT
Introduction: Although evidence indicates that head injury is prevalent in prisoners, little is known about the history of head injury in defendants during the Court process. This study assesses history of head injury and persisting sequelae in defendants undergoing Criminal Justice Social Work assessment for Court.
Methods: A cross sectional, between subjects design was used. Head injury history was assessed using the Ohio State University TBI Identification-Method and disability with the Glasgow Outcome Scale-Extended in 46 adult defendants undergoing a CJSW assessment in Scotland. Assessments of mental health, cognitive function, effort on tests and dysexecutive behavior were also carried out. Comparisons were made between defendants with and without a history of significant head injury.
Results: Significant head injury was found in the majority of participants (33/46; 72%) with 39% of these having persisting disability associated with the head injury. Those with significant head injury were more likely to have moderate-severe mental health difficulties, problematic alcohol or drug use and impairment on the Dysexecutive Questionnaire. Group differences were not found on cognitive tests or offending history. No CJSW report identified HI.
Conclusion: Disability, psychological distress, dysexecutive behavior and potentially harmful substance use are more common in defendants with SHI. The absence of differences on cognitive tests between those with and without significant head injury is consistent with other studies on offenders in Scotland. Training and a screening process for HI in CJSW assessments is needed to inform Court disposals and interventions and means of achieving this will be discussed.
436 The role of motor learning strategies in motor skills-based occupational therapy and speech-language pathology interventions for children and youth with acquired brain injury
Jennifer Ryana,b, Kristen Torchiac, Sofia Mirzazadac, Virginia Wrighta,b,d
aHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, cDepartment of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada, dDepartment of Physical Therapy, University of Toronto, Toronto, Canada
ABSTRACT
Introduction: Relearning motor skills is a critical component of pediatric acquired brain injury (ABI) rehabilitation. Motor learning strategies (MLS) are specific actions that clinicians use to promote motor skill acquisition based on child- and task-specific factors, and consist of therapist verbalizations (e.g., instructions, feedback), therapist actions (e.g., demonstration, physical guidance), or practice organization (e.g., repetition, variable practice). Although motor learning is central to physiotherapy intervention after ABI, research related to occupational therapy (OT) and speech-language pathology (SLP) tends to focus on the cognitive aspects of rehabilitation. While OT and SLP interventions may also address motor skills (e.g., fine motor skills, feeding, voice, motor speech), little is known about the application of MLS in these interventions. Thus, the aims of this study were to explore clinicians’ use of MLS in motor skills-based OT and SLP interventions for children and youth with ABI, and to explore differences in MLS application between these professions.
Methods: This qualitative descriptive study involved semi-structured interviews with four occupational therapists (OTs) and three speech-language pathologists (SLPs) who work in the ABI program at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada). Interviews used inductive questioning and were analyzed using in vivo coding, thematic analysis, and a modified constant comparison method.
Results: Three themes were generated: the role of (1) cognition in MLS application; (2) MLS in session planning and adaptation; and (3) clinician training in MLS use. Clinicians consider the child’s cognitive abilities when using verbal MLS and when deciding to combine cognitive and motor tasks. While clinicians begin a therapy session with a plan, they often adapt that plan (and associated MLS) based on the child’s level of engagement and performance. Clinicians use MLS that they have learned through formal and informal training opportunities, and value collaborating with other members of the child’s rehabilitation team to promote motor learning. While there were similarities in MLS application between OTs and SLPs, there were also profession-specific differences in their approach to motor skills-based interventions. For example, SLPs emphasized isolating the practice of specific motor skills before integrating them into a more functional task, whereas OTs appeared to integrate the motor skills into a functional task immediately.
Conclusions: This study provides a greater understanding of how OTs and SLPs view and apply MLS in their interventions. By exploring clinician perspectives, similarities and differences in MLS application were highlighted. These findings will contribute to the development a practice-informed MLS approach where all rehabilitation clinicians intentionally apply and reflect on MLS application in their interventions. By adopting an interdisciplinary approach to MLS application, it may be possible to identify an optimal set of MLS for a specific child and enhance their motor learning opportunities within and beyond the therapeutic setting.
437 Relationship between wait time and specialized multidisciplinary rehabilitation services for adults with mild traumatic brain injury with persistent symptoms: a mixed-method study
Julien Derya, Elaine De Guiseb, Marie-Eve Lamontagnea
aUniversite Laval, Quebec, Canada, bUniversite de Montreal, Montreal, Canada
ABSTRACT
Between 20% and 30% of adults with mild traumatic brain injury (mTBI) have persistent symptoms. Timely referral to a specialized multidisciplinary rehabilitation program (SMRP) is recommended to decrease symptom persistence. The objective is to explore how wait time is related to intensity and duration of services in a SMRP.
We conducted a sequential explanatory mixed method (QUAN->qual) including (1) a retrospective analysis of service delivery data between 2016–2020 and (2) a focus group with stakeholders from a SMRP. We used descriptive statistics, recursive partitioning, ANOVAs, and thematic content analysis.
We analyzed 529 patient records and met 15 providers. A longer time from referral to first service was associated with a reduction in the duration of rehabilitation and an increase in the intensity of services, which stakeholders explained in part as normal recovery from mTBI and as reaching a plateau when symptoms persisted after several months.
Our study highlights results at a specific program level, but further studies are needed to show broader impacts, such as economic, organizational, or societal. Robust evidence is essential to support the importance of timely multidisciplinary services to reduce symptom persistence.
438 The preservation of rich mental life and memory formation in a vegetative state patient
Lorina Nacia, Steve Beukemab, Laura Gonzales-Larac, Adrian Owenc, Damian Crused
aTrinity College Dublin, Dublin, Ireland, bDepartment of Ophthalmology, Montreal General Hospital, Montreal, Canada, cThe Brain and Mind Institute, University of Western Ontario, London, Canada, dSchool of Psychology, University of Birmingham, Birmingham, United Kingdom
ABSTRACT
A significant, small proportion of patients with disorders of consciousness (DoC) exhibit cognitive-motor dissociation (CMD), or the ability to follow commands with their brain activity, despite the complete absence of behavioral signs of consciousness. The detection of awareness via clinical behavioral testing is unlikely in these patients, unless advanced neuroimaging research protocols are available to complement clinical testing. Even when neuroimaging is available, and awareness is detected via brain-based command-following tasks, very little is known about these patients’ mental life. To address this question, here we asked whether CMD patients can attend to and continuously integrate information from their environment, leading to rich experiences that they may remember once they recover from the DoC. 11 patients DoC patients [6 vegetative state (VS), 4 minimally conscious state (MSC), 1 locked-in syndrome (LIS)] were tested, at Western University in Canada, with the Comma Recovery Scale-Revised and a previously-established command-following functional magnetic resonance imaging (fMRI) task (Naci et al 2014). Furthermore, the patients’ ability to attend to and integrate information over time was tested with a naturalistic fMRI task by Naci et al (2017), that involved listening to a suspenseful and plot-driven, brief (5 minutes) auditory narrative. One VS patient (P6), who regained consciousness within weeks of the research visit was brought back for a second visit, to assess whether he could recall any of the events from the first visit. We found evidence of CMD in patient P6. He was able to selectively attend to specific stimuli according to the researcher’s command, suggesting that he was conscious and could follow-commands via willful modulation of his brain activity. We also found evidence that the patient was able to process the sensory and higher-order features of the auditory narrative on a moment-to-moment basis, suggesting that he understood the narrative and could feel suspense similarly to every healthy individual. Critically, in the second visit, the patient recalled freely several details of his first visit and successfully performed a personalized forced-choice recognition task, providing evidence of intact memories from the period when he was clinically deemed to be in a vegetative state. These results suggested that the patient retained a much more sophisticated mental life than could be inferred by his clinical diagnosis of VS, and even the CMD classification. He demonstrated several high-level cognitive faculties, and an active mental life, including the ability to attend to, integrate and understand high-level auditory information continually for a period of time. These findings were corroborated by the patient’s report of a rich memory of his experience during the time when he was deemed unconscious. This case presents an important opportunity to examine our moral obligations to vulnerable patients and decision-making on their behalf.
440 Emergency department visits for mild traumatic brain injury in young children
Sean Rosea, Deborah Levinea, Junxin Shia, Krista Wheelera, Rachel Stanleya, Miriam Beauchampa
aNationwide Children’s Hospital, Columbus, USA
ABSTRACT
Background: Mild traumatic brain injury (mTBI) during early childhood may disrupt key periods of neurodevelopment. Most research regarding mTBI has focused on school-age children. We sought to characterize the incidence and healthcare utilization for mTBI in young children presenting to U.S. emergency departments (ED).
Methods: The Nationwide Emergency Department Sample was queried for children age 0–6 years with mTBI from 2016–2019. Patients were excluded for focal or diffuse TBI, drowning or abuse mechanism, death in the ED or hospital, Injury Severity Score > 15, neurosurgical intervention, intubation, or blood product transfusion.
Results: National estimates included 1,372,291 patient visits: 63.5% were two years or younger, 57.5% were male, and 69.4% were injured in falls. The most common head injury diagnosis was “unspecified injury of head” (83%); this diagnosis decreased in frequency as age increased, in favor of a concussion diagnosis. Most patients were seen at low pediatric volume EDs (64.5%) and non-children’s hospital EDs (86.2%), and 64.9% were seen at a non-teaching hospital. Over 98% were treated in the ED and discharged home. Computed tomography of the head was performed in 18.7% of patients, more often at non-children’s hospitals and hospitals that treat fewer children (P < 0.001). ED charges resulted in $540-681 million annually, and more than half of patients utilized Medicaid.
Conclusions: Early childhood mTBI is prevalent and results in high financial burden in the U.S. There is wide variation in diagnostic coding and computed tomography scanning amongst EDs. More focused research is needed to identify optimal diagnostic tools and management strategies.
443 Lessons from domestic violence survivors and practitioners in developing and implementing a project on acquired brain injury
Stephanie Becheleta, Annmarie Burnsa, Sara Da Silva Ramosa
aThe Disabilities Trust, Burgess Hill, United Kingdom
ABSTRACT
Objectives: Domestic violence and abuse (including intimate partner violence, IPV) is one of the top causes of acquired brain injury in women around the world (e. g. Kim, et al., 2022; Valera, et al., 2021). However, studies with survivors and practitioners have shown that brain injury and its effects are not widely recognized nor regularly assessed in this population (Manoranjan et al., 2022; Haag et al. 2019; Nemeth, et al., 2019). The aim of this paper is to describe how we engaged with domestic abuse survivors and practitioners who support them to co-produce a new study investigating the cognitive and emotional effects of acquired brain injury and its relationship with psychological trauma.
Methods: We began by engaging a network of practitioners to explore their levels of understanding and awareness of acquired brain injury (The Disabilities Trust, 2021). A roundtable event and a survey of professionals indicated that practitioners perceived their own awareness and knowledge of brain injury as limited, and they reported that training is not readily accessible. It was also acknowledged that there is limited UK evidence on the prevalence and impact of brain injury in survivors of domestic abuse. These findings led to working in collaboration with SafeLives’ Leading Light Services with the aim of piloting the use of a brain injury screening tool in community based domestic abuse services. A study protocol was designed, building on previous research within female prison settings (O’Sullivan et al., 2021) and trauma support services for veterans (Murphy et al., 2015). Two panels with domestic abuse survivors and practitioners further informed and shaped the design.
Results: This co-production process resulted in a number of insights and points for reflection that may be useful to inform future research and practice. For example, the possible impact of inclusivity, social context and terminology on survivors’ participation in research and its results, as well as ways to address the challenges surrounding confidentiality, disclosure and safeguarding.
Conclusions: Our findings reiterate the importance of co-production in research. We discuss its added value specifically in the context of research within the field of acquired brain injury with survivors of domestic abuse.
445 Traumatic brain injury in ireland: initial findings from a national study
Andrea Healya, Kate O’Donnella, Anthony Stainesa, Catherine Corrigana, Teresa Burkreb, Brian Waldronb, Grainne McGettrickb
aDublin City University, Dublin, Ireland, bAcquired Brain Injury Ireland, Dublin, Ireland
ABSTRACT
Background: Traumatic brain injury (TBI) is a major public health concern and a leading cause of death and disability worldwide. In Ireland, a dearth of research on TBI means that we neither know the number of people affected by head injury, nor have the information required to explore neuro-rehabilitation services that support optimal outcomes for individuals with TBI and their families. This study focused primarily on pathways through rehabilitation post TBI in Ireland.
Methods: This research was a mixed-methods, observational cohort study design. One hundred and twenty-one participants with TBI were recruited through two major trauma centers, two national brain injury services and a rehabilitation hospital. Participants with TBI were surveyed on two separate occasions six months apart, and EQ-5D 3L, WHOQOL BREF and EBIQ instruments administered. Carers or family members of participants with TBI were surveyed once. This paper reports on the first interviews with participants with TBI. Data from second interviews and interviews with carers or family members will be reported elsewhere.
Results: Almost 50% of participants reported having received rehabilitation in the acute hospital. Participants reported inpatient rehabilitation was recommended in 55.8% of cases; outpatient rehabilitation in 62.5% of cases; and community rehabilitation in 52.1% of cases. Over 66% of participants reported that their employment status changed as a result of their injury and 30.6% of respondents indicated that post-injury they were not working due to permanent sickness or disability. A comparison of mean scores for females and males on the EBIQ subscales revealed significant differences between females and males on the subscales of isolation (Female, M = 1.64, SD = 0.476, Male M = 1.88, SD = 0.488; t (118) = −2.48, p = 0.015, d = 0.485); communication (Female, M = 1.57, SD = 0.469, Male M = 1.85, SD = 0.565, t (118) = −2.56, p = 0.012, d = 0.540) and cognitive (Female, M = 1.59, SD = 0.436; Male M = 1.80, SD = 0.456, t (118) = −2.36, p = 0.020, d = 0.448).
Discussion: Access to rehabilitation services varied substantially for moderate to severe TBI survivors with male survivors experiencing more difficulties than females in their quality of life. Improved and equitable access to rehabilitation services is necessary to ensure better outcomes for TBI survivors in Ireland.
446 Treatment burden in stroke survivors in ireland and the impact on self-care
Valerie Twomeya, Brian McGuireb
aNational Rehabilitation Hospital, Dublin, Ireland, bUniversity of Galway, Galway, Ireland
ABSTRACT
In Ireland, approximately 10,000 people will have a stroke event each year and there is currently 30,000 people living in Ireland with disabilities as a result of stroke (McElwaine, McCormack & Harbison, 2016). Advances in modern healthcare have led to improved patient outcomes following stroke, however, the challenges to the healthcare system in recent years has placed an increased burden on patients to self-manage their individual healthcare needs. Excessive treatment burden can negatively affect outcomes. The aim of this thesis was to explore whether treatment burden exists in stroke survivors and to examine to what extent this burden impacts on self-care. Using a qualitative research approach called Interpretative Phenomenological Analysis (IPA), this study explored the experiences of six stroke survivors as they engaged in neurorehabilitation and set about managing their self-care. In depth interviews with six stroke survivors were carried out and analyzed using the principles of IPA. Analysis of the data revealed a series of superordinate and overarching themes for each participant and a set of common themes which reflect stroke survivors’ experiences. Themes included ‘sense making,’ ‘profound loss’ and ‘acceptance.’ Overall there was no evidence of treatment burden in this study and participants were self-managing their healthcare needs with personal and professional support. This thesis provides important insights into the concept of treatment burden as experienced by stroke survivors in Ireland, the factors that affect their experience of, and capacity to, manage their care. Findings have important implications for the improvement and redesign of healthcare delivery.
447 Innovative collaboration between educational psychology and health and social care trust services in northern ireland: providing multi-agency training to schools in relation to acquired brain injury (ABI), raising awareness of abi in schools and supporting school staff at every stage of the child’s education
Ruth Nesbitta, Maria Martin-McKeevera, Victoria Millera, Eunan McCruddenb, Katie Burnsb, Naomi Brownb
aEducational Psychology Service, Education Authority, County Antrim, United Kingdom, bChildren’s Acquired Brain Injury Consultation Service, Belfast Health and Social Care Trust, Belfast, United Kingdom
ABSTRACT
The “Acquired Brain Injury Pathway for Children and Young People” in Northern Ireland (Regional Acquired Brain Injury Implementation Group (RABIIG), 2014) outlines the need for both “comprehensive communication between health and social care services and school” (RABIIG, 2014, p 12) and “involvement of education services … to facilitate comprehensive transfer of information from the clinical to the educational setting” (RABIIG, 2014, p 12), when a child or young person is discharged from hospital and is preparing to return to an education setting. Despite the above, there is no known service within Northern Ireland that provides this level of partnership or joined up working. Therefore, representatives from the Educational Psychology Service and the Children’s Acquired Brain Injury Consultation Service (ABCs) within the Belfast Health and Social Care Trust developed a programme of training for schools. The team is comprised of Educational Psychologists, Assistant Educational Psychologists, Occupational Therapist, Speech and Language Therapist and Clinical Psychologists, offering a wide range of expertise and sources of advice. Our unique training covers various topics including supporting the child on return to school and considering specific areas of difficulty such as environmental demands, peer relationships, and physical or cognitive impairment. It is imperative to build capacity within schools as lack of training can result in “educational and psycho-social interventions being compromised” (RABIIG, 2014, p 13). Our training therefore raises awareness of key services, including Children’s ABCs, to further support schools. Fifty-two participants have completed the training from 43 educational settings. Qualitative feedback indicates that the training increases theoretical knowledge of brain injury and provides practical and relevant resources and strategies. Participants reported that the training will help school staff to “improve integration and support” for children, “set more appropriate targets,” “liaise more with specialists in ABI” and “open more lines of communication.” The training will be expanded to focus on particular school-age settings, as well as consultation sessions on specific topics of interest. This project acknowledges the need to raise awareness of ABI in schools and the benefit of providing early intervention to improve long term outcomes. Our multi-agency approach is vital to address the individual, complex and changing presentation of ABI throughout a young person’s education journey.
Reference
Regional Acquired Brain Injury Implementation Group. (2014). Acquired Brain Injury Pathway for Children and Young People. Health and Social Care Board.
448 Family functioning following early childhood brain injury: parent and child perspectives
Libby Darta, Brenda Eagan-Johnsonb, Erika Hagenc, Drew Nageled, Monica Vaccaroe, Nicole Violac, Jennifer Lundinec, Angela Cicciaa
aCase Western Reserve University Dept of Psychological Sciences, Cleveland, USA, bBrainSTEPS Brain Injury School Consulting Program, Harrisburg, USA, cThe Ohio State University, Columbus, USA, dNagele NeuroRehab Consulting, LLC, Philadelphia, USA, eBrain Injury Association of Pennsylvania, Philadelphia, Philadelphia, USA
ABSTRACT
Objectives: 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 performance of students in grades K-12 who have experienced TBI of any severity, compared to students who have no formal RTS programming. This session will specifically examine the family functioning of children who experienced a TBI before entering formal schooling.
Methods: STATBI uses a mixed method, cohort-controlled research design. The IRB-approved protocol includes electronic survey administration and virtual interviews with parents and children. The data included in this presentation is cross-sectional, although the full STATBI protocol is longitudinal. Measures in the sample for this presentation include standardized assessments of family functioning and child behavior, in addition to semi-structured interviews with parents and children regarding their family functioning. The McMaster Family Assessment Device (FAD) general functioning subscale short version was used to measure family functioning, with higher scores indicating worse family functioning. The Child Behavior Checklist (CBCL) was used to measure child behavior, with higher scores indicating problematic behavior. This presentation used a sequential, exploratory design.
Results: At the time of submission, 7 children between the ages of 0–5 were included in this sample. Of these children, 50% were female, and 50% were white (25% multiracial, 12.5% black, 12.5% Hispanic). The mean age of injury was 3.5 years (SD = 1.8 years of age). Additionally, 50% sustained a severe TBI, 12.5% moderate, and 37.5% mild. 50% of TBIs were caused by motor vehicle accidents. Results of family functioning and child behavior are being analyzed for descriptive and comparative purposes and will be available at the time of this presentation. Interviews with caregivers and students are also being analyzed using reflective thematic analysis to identify the themes expressed by these key stakeholders. We will evaluate themes related to the family experience with early childhood brain injury and explore this data with the quantitative results to inform a comprehensive discussion of the unique impact of early brain injury on family functioning and behavior. Recruitment is ongoing and updated data will be available at the time of the presentation.
Conclusions: The STATBI project is unique in its focus on RTS for youth with TBI, and this presentation will specifically describe the family functioning experiences of a sample of school-aged youth that have sustained early childhood TBI. The integration of quantitative and qualitative data analysis identified in this work will add to the growing body of knowledge related to family functioning for school-age students who sustained a TBI before entering formal schooling and how this could be used to further intervention.
449 Reduced temporal contiguity of narrative recall in adults with moderate-severe traumatic brain injury
Sharice Clougha, Melissa Evansb, Sarah Brown-Schmidtb, Melissa Duffa
aVanderbilt University Medical Center, Nashville, USA, bVanderbilt University, Nashville, USA
ABSTRACT
Background: Episodic memory recall is organized by temporal proximity and often examined via list learning paradigms. The Temporal Continuity Effect reflects the tendency of individuals to transition between nearby items in the study list, and the Asymmetry Effect reflects the tendency to recall nearby items in a forward direction. Although such tasks have yielded robust insights into memory organization during free recall, they lack ecological validity. Much of day-to-day learning occurs through narratives, conversations, and social interactions with others. These memories are embedded in both a semantic and temporal context. We examine whether temporal organization is disrupted by brain injury in more naturalistic contexts by comparing the temporal organization of narrative retellings of adults with and without moderate-severe traumatic brain injury (TBI).
Method: Participants were 60 adults with moderate-severe TBI in the chronic phase of their injury (>6 months post) and 60 non-brain injured comparison participants matched pairwise on age, sex, and education. Participants watched videos of a narrator telling four short stories. Stories contained 6 sentences, were ~30 seconds long, and were divided into 10–12 story details. Participants retold the stories immediately, 20 minutes later, and one week later. We calculated conditional response probability as a function of serial position lag (lag-CRP). Lag refers to the difference between two sequentially recalled story details in terms of the original presentation order of those details by the narrator. Lag-CRP is the probability of a transition given all possible transitions that could have been made. Finally, temporal organization scores reflect the degree to which a given recall was organized temporally.
Results and Discussion: Like non-brain injured peers, participants with TBI demonstrated a tendency to recall story details in a forward direction. However, relative to non-brain injured peers, participants with TBI were less likely to make a + 1 transition to the nearest sequentially presented detail. Although their narrative retellings were temporally organized above chance levels, participants with TBI exhibited significantly lower temporal organization scores than non-brain injured peers (B = 0.069, t = −4.10, p < 0.001). There was also a significant effect of long delay; participants exhibited significantly lower temporal organization scores when retelling stories one week later compared to immediately after hearing the stories (B = 0.070, t = −5.36, p < 0.001). A lack of interaction between group and delay suggests that the negative effect of long delay on temporal organization of narrative recall did not differ by group. Participants’ memory for the stories predicted temporal organization scores across groups. Decreased temporal organization of narrative recall may put individuals with TBI at increased risk for poorer communication and social outcomes. Examining temporal memory demands of everyday language may improve detection of cognitive-communication impairment in laboratory and clinical settings and lead to new mechanistic accounts of communicative disruption in TBI.
451 Bridging the gap of integration in specialist neurorehabilitation: development of the brain injury outreach specialist role
Valerie Twomeya, Catríona Morana
aNational Rehabilitation Hospital, Dublin, Ireland
ABSTRACT
The National Rehabilitation Hospital (NRH) is the only tertiary level complex specialist rehabilitation center in Ireland. Waiting times for access to this center are lengthy. In response to feedback from stakeholders, particularly in the acute setting, seeking advice and support while awaiting access to the NRH a new role was developed with the aim of connecting and supporting local teams, patients and their families. A pre-admission outreach and liaison service was developed.
An Outreach Specialist (health and social care professional) visit acute hospitals where patients with complex acquired brain injuries are awaiting access to the NRH. Outreach visits are triggered by consultants not specialists in brain injury or by Rehabilitation Medicine Consultants following triage of a referral.
The outreach visits involve liaising face to face with treating teams, formal assessment of the patient, joint treatment sessions with the treating teams as requested, meetings with families and outside agencies e.g. community brain injury services and primary care teams.
Meeting with teams and families has allowed for increased transparency about the rehabilitation process. With increased communication between agencies it has allowed for a better understanding of acquired brain injury and what can be done while they await access to the tertiary center. A face to face meeting in the acute setting allows for clear explanation on what to expect during the patient journey. It also allows for streamlined handover of advice and recommendations. It can offer prompts for local teams to begin the process for longer term care as appropriate.
The service is resulting in earlier access to rehabilitation in with complex case management that is individualized and patient centered. It involves both outreach and inreach where the specialist seeks advice from interdisciplinary colleagues within the NRH. In some cases, in conjunction with community brain injury services and the acute hospitals, an admission to the NRH has been deemed not appropriate for the individual as it is felt that their needs would be better met in the more meaningful and contextual environment of home with rehabilitation services locally.
Overall with increased communication along the whole continuum of care and engagement in long term planning it has been observed that family expectations and distress are being managed. With work done on long term planning and identification of a long term placement option prior to admission to the NRH this then further reduces numbers of delayed discharges and transfer back to the acute hospitals. This also allows for an improved transition of care from the rehabilitation setting to care staff in the home or in the long term care placement.
452 Development of a pediatric functional status escore for children with neurologic injuries and illnesses
Jennifer Lundinea, Jared D. Hulingb, Julie C Leonardc
aThe Ohio State University, Columbus, USA, bUniversity of Minnesota, Minneapolis, USA, cAbigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, USA
ABSTRACT
Objectives: The long-term sequelae of pediatric neurologic injuries and illnesses pose a significant societal burden, yet the evidence supporting the long-term effectiveness of rehabilitation interventions is weak. The primary objective of this study was to provide proof of concept for development of a Pediatric Functional Status eScore (PFSeS). As a first step, we demonstrate that expert clinicians rank billing codes (procedural, diagnosis, pharmaceutical, and durable medical equipment) as relevant to patient functional status and identify the domains that codes inform in a way that reliably matches analytical modeling to promote future clinical effectiveness research.
Methods: Researchers examined claims data from 1,955 unique patients and 2,029 hospital admissions. All hospitalizations included admission to an inpatient rehabilitation at one large US midwestern children’s hospital between 1/2000 and 12/2020. Researchers include specific demographic data and discharge WeeFIM® ratings (assessment of functional independence) to assist in building the PFSeS model. In a series of surveys, a consensus process with 12 experts in pediatric rehabilitation care reviewed 2,893 codes and determined which codes should be included in modeling the PFSeS and the clinical domains they informed (mobility, self-care, cognition/communication).
Results: The top 250 and 500 codes identified by statistical modeling were mostly comprised of codes selected by the consultant panel (78–80% of the top 250 and 71–78% of the top 500), demonstrating evidence that statistical modeling reliably identified the codes most predictive of functional status. The top 5 codes most strongly related to domain specific WeeFIM® ratings indicate clinically sensible relationships, further supporting the use of billing data in modeling to create a PFSeS.
Conclusions: Development of a PFSeS that is predicated on billing data would improve researchers’ and clinicians’ ability to assess the functional status of children who receive inpatient rehabilitation care for a neurologic injury or illness. An expert clinician panel, representing the spectrum of medical and rehabilitative care, indicated that proposed statistical modeling identifies relevant codes mapped to three important domains: self-care, mobility, and cognition/communication.
453 Supporting patients through the rehabilitation continuum of care: the NRH rehabilitation coordinator
Valerie Twomeya, Léana Colgana, Orla McEvoya
aNational Rehabilitation Hospital, Dublin, Ireland
ABSTRACT
The National Rehabilitation Hospital (NRH) is the only tertiary level provider of complex specialist rehabilitation in Ireland. The Brain Injury Programme (BIP) provides in-patient specialist rehabilitation to people following an acquired brain injury. The national demand for this service far exceeds the number of beds and resources available.
Because of lengthy waiting lists to the service for patients with with diverse and complex rehabilitation needs, the waiting time for admission is extensive, i.e. waiting longer than 6 months. Previously, patients may have been admitted to the incorrect stream of rehabilitation or admitted inappropriately to other healthcare facilities as there has been poorly coordinated continuity of care throughout the entire rehabilitation process. The absence of service provision for those waiting for admission has resulted in distressed families and referrers and a high percentage of delayed discharges in both the acute sector and the rehabilitation setting due to late collaboration with community and primary care services.
In 2016, it was identified that a solution to the fragmented arrangement of services to patients with acquired brain injury was required. As a result, the Preadmission Service at NRH was established to optimize the transition of care from acute through to community settings including rehabilitation and discharge. The service aims to meet the standards set out by the National Waiting List Management Protocol 2017. The preadmission service collaborates directly with the patient and their family when appropriate, plus a wide range of clinicians and agencies.
The service led by a Rehabilitation Coordinator is resulting in improved patient outcomes across several domains that can be described qualitatively and quantitatively. The effect is a reduction in waiting times for admission, the provision of effective intervention while waiting for admission and reducing the numbers of delayed discharges plus returns to the acute setting.
454 Neuropsychological test performance in young patients (15–30 years) with persistent post-concussion symptoms: a cross-sectional study
Mille Moeller Thastuma, Erhard T. Næss-Schmidta, Andreas Schröderb, Charlotte Ulrikka Raskc, Jørgen Feldbaek Nielsena, Lars Evalda
aHammel Neurorehabilitation Center and University Research Clinic, Aarhus University, Hammel, Denmark, bThe Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Aarhus, Denmark, cDepartment of Child and Adolescent Psychiatry, Research Unit, Aarhus University Hospital Psychiatry, Aarhus, Denmark
ABSTRACT
Background: Self-reported cognitive symptoms due to a complex interplay between biological, psychological and social factors are prevalent in patients with persistent post-concussion symptoms, and may limit return to work, school, and social life. Therefore, patients are often referred to neuropsychological testing. However, the clinical value of this practice has continuously been debated due to the limited sensitivity of neuropsychological tests to mild cognitive dysfunction, and due to its limited differential diagnostic value. Nevertheless, neuropsychological testing is widely applied in both clinical and research settings, and therefore there is a need to identify which tests may be most sensitive to mild cognitive dysfunction after concussion.
Aim: In a cross-sectional study, to explore the performance of young patients with persistent post-concussion symptoms on neuropsychological testing, and to investigate which subtests may be most sensitive to possible mild cognitive impairment in this population.
Methods: The present study was embedded in a Magnetic Resonance Imaging-study (ClinicalTrials.gov. NCT02350894) investigating possible microstructural changes in patients with persistent PCS (Rivermead Post-concussion Questionnaire score > 20) 2–6 months post-concussion. In total, 50 patients (15–30 years) were consecutively recruited from a cohort study or referred by general practitioners. Patients were assessed with a comprehensive battery of 9 neuropsychological tests covering processing speed, attention, learning and memory, test effort, and executive functions. Mean z-scores of the different subtest measures were calculated based on normative data. Number of patients performing below z-score 1.66 (corresponding to the 5th percentile) was considered on each subtest measure.
Results: Mean z-scores varied from – 0,77 to 0,68 across cognitive domains. On 17 out of 29 measures more patients than expected from normative data were observed performing below the 5th percentile. The profile of mean z-scores and an overview of the caseness frequency on the individual neuropsychological subtests will be presented.
Conclusion and Perspectives: In total, 17 out of 29 subtest measures seemed sensitive to mild cognitive impairment after concussion based on the caseness criterion. In clinical practice and neurocognitive research, it may be helpful to apply a small battery of tests most sensitive to mild cognitive dysfunction rather than comprehensive testbatteries. More research is needed to identify such tests.
455 Developing a clinical screening protocol for victims of head trauma: a qualitative trial through collaborative working, measured outcomes and smart strategies
Heather Bateya, Lisa Powella
aReach Personal Injury Services, 14 The Stables, Newby Hall, United Kingdom
ABSTRACT
Background: Head injuries account for over a million hospital attendances each year in the UK, with the majority categorized as mild and not referred for diagnostic imaging. Additionally, mild head traumas are often missed when presenting alongside serious injuries, such as those sustained in high-energy impacts. A major insurer identified a significant number of claims that surpassed allocations because mild traumatic brain-injury (mTBI) went undiagnosed near the time of accident and they approached Reach to help to improve their claim predictions.
Solution: Reach found insufficient provision for assessment of this client group, so established appropriate assessment and outcome measures and developed a screening protocol to improve early identification of red-flags including cognitive fatigue, executive function deficit and social engagement issues. Clients were triaged accordingly and either referred to external treatment providers or recommended for further assessment and therapy. Exclusion criteria: GCS < 13; suspected cerebral cortex damage; prolonged unconsciousness (> 15 min); pre-accident psychotic or substance abuse.
Outcome: We piloted the screening tool in 2021 nationally for 25 cases, 17 of which would require specialist neuro-occupational therapy intervention for post-concussive symptoms, a number that was far higher than anticipated. It is too early for longer term outcome data to be available, however early outcome scores are very promising. The specific outcome measures within the Rivermede Post-Concussion Questionnaire and the Warwick and Edinburgh Mental Wellbeing Scale were key in identifying and measuring progress. The key areas of progression, following intervention, based on the outcome scores were improved: – fatigue (85%;) concentration (80%); pain (60%); ‘feeling optimistic’ (75%) and ‘feeling good about myself’ (70%), which lead to increased functional activity (100%) and return to work (85%). We expect increased availability of outcome data to strengthen our findings.
Discussion: It is difficult to evince the prevalence of untreated mild head trauma and the socio-economic impacts from its long-term effects, but absence of evidence is not evidence of absence and given the sheer volume of patients, the current best practice and available diagnostic tools, it is apparent that a significant number of cases are left untreated. It is now widely accepted that there can be significant neurological consequences from the long-term effects of mTBI, in addition to a body of evidence that supports early intervention as the gold standard to minimize such consequences. Whilst advances into the study of biomarkers to predict mTBI and some of its long-term sequelae continue to be made, many cases will continue to go undetected until such advances can be developed into relatively simple and reliable blood or saliva tests. Until these advances are introduced to clinical practice the Reach head trauma triage protocol provides an economic screen for patients that may otherwise remain undiagnosed.
456 Educator perspectives of supporting students to return to school following a concussion
Heather A Shepherda,b,c,d, Isla Shilla,b,c,d, Keith Owen Yeatesb,c,e, Nick Reedf,g,h, Jeffrey Caroni,j, Kathryn Schneidera,b,c,k,l, Amanda Blacka,b,c,d, Carolyn A Emerya,b,c,d,m
aSport Injury Prevention Center, University Of Calgary, Calgary, Canada, bAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, cHotchkiss Brain Institute, University of Calgary, Calgary, Canada, dO’Brien Institute for Public Health, University of Calgary, Calgary, Canada, eDepartment of Psychology, University of Calgary, Calgary, Canada, fDepartment of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada, gRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, hBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, iSchool of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Canada, jCenter for Interdisciplinary Research in Rehabilitation, Montreal, Canada, kSport Medicine Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, lEvidence Sport and Spine, Calgary, Canada, mDepartments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
ABSTRACT
Background: Up to 75% of high school students require academic accommodations following a concussion. Educators are tasked with providing supports, such as academic accommodations, to students returning to school following a concussion. However, limited research has described the prevalence and feasibility of providing academic accommodations to students following a concussion, nor explored educators’ perspectives with supporting students returning to school following a concussion.
Purpose: To explore the 1) prevalence and feasibility of providing academic accommodations to students following a concussion; 2) resources available to support students returning to school following a concussion; and 3) perspectives of educators supporting students returning to school following a concussion.
Methods: This study employed an additional coverage mixed-methods design with middle school and high school (grades 7–12) teachers and school administrators across Canada. The study included a cross-sectional survey administered online and qualitative interviews conducted via Zoom. The survey used descriptive statistics to examine the 1) prevalence of academic accommodations; 2) feasibility of providing academic accommodations; and 3) concussion management practices. The interviews were guided by an interpretivist paradigm and were analyzed using reflexive thematic analysis to understand the perspectives of educators supporting students returning to school following a concussion.
Findings: 180 educators (138 teachers and 41 school administrators) completed the survey and 18 educators (13 teachers and 5 school administrators) participated in an interview. Based on the survey, 41% (69/167) of participants indicated their school had a concussion management plan. Eighty-six percent (153/176) of educators had previously provided academic accommodations to a student following a concussion and 96% (172/179) of educators believed it was important or very important that students with concussion have access to accommodations. Educators reported that some accommodations (e.g., extra time 89%, 154/173) were provided more often than other accommodations (e.g., no new learning, 32%, 54/170) and some accommodations were more feasible to provide than other accommodations. The qualitative interviews resulted in five themes which provided additional context to survey findings: 1) teacher and administrator roles; 2) students’ symptoms affect their learning; 3) students should have access to accommodations; 4) supporting students socially and emotionally; and 5) concussion education and management processes are insufficient.
Conclusions: Teachers and school administrators have different roles when supporting students returning to school following a concussion, but they both share a desire to support students through academic and social support. Limited school resources affect educators’ ability to provide academic accommodations. Further, schools need to prioritize concussion education and implement concussion management processes to ensure students are supported following a concussion.
457 A psycho social evaluation of an alcohol related brain injury specialist residential rehabilitation service in northern ireland
Anne Campbella, Naomi Browna
aLeonard Cheshire, Belfast, United Kingdom
ABSTRACT
Background: Initiatives are required in order to identify and provide rehabilitation for individuals with Alcohol Related Brain Injury (ARBI). However, there is very little evidence as regards the outcomes and lived experiences of the patients who often have a myriad of corollary problems including alcohol dependency, homelessness, family dysfunction and contact with the criminal justice system. Leonard Cheshire has developed a specialist residential rehabilitation facility for people in Northern Ireland with Alcohol related Brain Injury (ARBI). This service is one element in the network of services required to support people with ARBI.
Methods: This mixed methods study explored the effectiveness of an ARBI treatment modality available for patients in Northern Ireland on an inpatient basis. It utilized a range of quantitative measures to assess psychological well-being, functional ability, familial and social relationships/ community participation/ cognitive ability and maintaining abstinence at base line and at five junctures throughout the project time frame. Qualitative data was collected over 4 timepoints: baseline (n = 20), 6 months (n = 15), 12 months (n = 6) and at follow up post discharge (n = 4). Remote interviews were conducted with family members (n = 10). Staff interviews captured views on the implementation of the model as well as their perceptions of strengths, weakness and benefits of the service and external influences that might affect its implementation and effectiveness.
Findings: There were significant differences in scores across T1- T2 and T3 time points for HADs Depression, Anxiety and HONOS scores. Qualitative findings for residents across 4 timepoints from baseline to time of discharge indicated an overall improvement in all outcomes. In addition, relatives stated that the ARBI model had significantly improved outcomes for their loved ones and had provided a ‘safe space’ in which they could recover and rebuild themselves. Staff from within the unit felt that the ARBI multidisciplinary holistic approach had a positive impact on residents’ outcomes and was cost effective in that these individuals were no longer frequenting A&E departments and the judicial system and instead were now able to live stable lives without relentless chaos.
Conclusion: Overall, the ARBI holistic intervention significantly improved psychological wellbeing, social relationships/ community participation, cognitive abilities and abstinence from alcohol, particularly when residents were residing in the unit. Whilst the residential unit provided structure and a protective environment, residents required ongoing support post discharge for their addictive behaviors. An outreach intervention for these individuals is currently being piloted.
458 Ultra-low field portable MRI in the young is a reliable alternative to 3T MRI in low resource settings
Niall Bourkea, Kirsten Donaldb, Jessica Ringshawb, Layla Bradfordb, Marlie Milesb, Chloe Jacobsb, Reese Samuelsb, Tracey Panb, Nwabisa Mlandub, Tembeka Mhlakwaphalwab, Steven Williamsa
aKing’s College London, London, United Kingdom, bUniversity of Cape Town, Cape Town, South Africa
ABSTRACT
Portable low-field MRI has the potential to make a huge positive impact on access to MRI across the world. In low-middle income countries or low resource settings it can provide visualization of healthy brain development or the detrimental effects of a variety of conditions including traumatic brain injury, infection or hypoxic ischemic encephalopathy. Potentially useful biomarkers such as brain volume estimates can be generated semi-automatically through integrated biomedical data platforms removing the need for local neuroimaging analysis expertise. In the current study we present analysis workflows that apply complex algorithms to process neuroimaging scans providing cortical gray matter and white matter volume estimates in two pediatric cohorts from a remote collaborative site in South Africa. High resolution 1 mm isotropic structural T1w and T2w acquisitions were acquired on a 3 Tesla MRI. Additionally, structural images were acquired in three separate acquisitions (1.5 mm x 5 mm x 5 mm) across axial, coronal and sagittal planes on a portable 0.064 Tesla MRI scanner (Hyperfine Swoop). These separate acquisitions were combined using the software package ANTs to generate an isotropic image for volume estimation performed with Freesufer SynthSeg. White and gray matter volume both had a strong correlation across scans (R = 0.8, p < 0.01). We demonstrate the feasibility of cortical segmentation with ultra-low field MRI in neonates for the first time and a strong correlation to high field MRI. This workflow will be applied to a consortium of clinical partners in low and middle income countries in Africa and south Asia examining the detrimental effects of conditions including maternal anemia, malnutrition and infection on the baby brain. Portable low field MRI scanners and standardized analysis workflows enable wider access to detailed neuroimaging where previously not feasible at a fraction of the cost. Developing neuroimaging hardware and software technology will improve access to resources for assessment of brain injury.
459 “Lean on me”: describing what high school students want in a peer support program following a concussion
Heather Shepherda,b,c,d, Carla van den Berga,b,d, Jeffrey G Carone,g, Nick Reedg,h,i, Keith Owen Yeatesb,c,j, Carolyn A Emerya,b,c,d,k
aUniversity Of Calgary, Calgary, Canada, bAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, cHotchkiss Brain Institute, University of Calgary, Calgary, Canada, dO’Brien Institute for Public Health, University of Calgary, Calgary, Canada, eSchool of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Canada, fCenter for Interdisciplinary Research in Rehabilitation, Montreal, Canada, gDepartment of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada, hRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, iBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, jDepartment of Psychology, University of Calgary, Calgary, Canada, kDepartments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
ABSTRACT
Background: Concussions are prevalent among high school students. Peer support has been suggested as one way to provide social and academic support for students returning to school following a concussion. However, it is not well understood what high school students would like in a peer support program. The purpose of this study was to describe how high school students conceptualized a peer support program for students following a concussion.
Methods: Through the lens of a pragmatic paradigm, we conducted a qualitative case study in one Calgary, Alberta, Canada high school. All participants were enrolled in a sports medicine course. Semi-structured focus groups (ngroup = 7) were conducted during class time with 53 high school students in grades 10–12 (16M, 36 F, 1 prefer not to disclose; median age = 16, range = 15–18). Students had either previously sustained a concussion (n = 20) or were interested in supporting a peer who had sustained a concussion (n = 33). Focus groups aimed to describe what factors should be included in a peer support program for students after a concussion. Focus groups were analyzed inductively using conventional content analysis.
Findings: The focus groups resulted in three primary themes: 1) students wanted a one-on-one relationship with a peer they trust; 2) schoolwide education should be available to all school stakeholders; and 3) barriers to a school-based peer support program could affect uptake of the peer support program. Participants shared that a one-on-one “buddy” peer support program was preferred as it allowed for trust, confidentiality, and flexibility in how support was offered (e.g., social, emotional, academic, advocacy, education). Barriers to program uptake included stigma, lack of concussion reporting, and limited availability of “buddies” to support the students with a concussion. According to the participants, preferred strategies included a one-on-one buddy system, schoolwide concussion education, compensation for being a buddy, and increased awareness to the peer support program to mitigate potential barriers.
Conclusions: A one-on-one “buddy” peer support may providethe confidential and tailored support high school students are seeking when returning to school following a concussion.
460 Family quality of life after acquired brain injury: a qualitative exploration of primary and non-primary caregivers’ perceptions
José Luis Castilloa, Alba Azaa, María Fernándeza, Miguel Ángel Verdugoa
aInstitute On Community Integration (INICO, University Of Salamanca), Salamanca, Spain
ABSTRACT
Introduction: After an Acquired Brain Injury (ABI), families are pivotal for care and support provision to survivors. However, this has a profound impact on family life and their well-being as a unit. Frequently, quality of life of family members and family functioning are studied from the perspective of the caregiver, neglecting other relatives’ experiences. Analyzing both type of experiences is essential for enhancing family quality of life.
Aim: To understand what family quality of life is from primary caregivers and non-primary caregiver family members’ perspectives, and to identify differences between them.
Methods: Twenty-two primary caregivers and fourteen non-primary caregiver family members of persons with ABI (Cerebrovascular accident = 15; Traumatic brain injury = 11; Anoxia = 5; Tumor = 4; Brain infection = 1) were recruited across Spanish Brain Injury Federation. Five focus groups about family well-being were conducted. Following verbatim transcription, a thematic analysis (Braun & Clarke, 2006) was performed to identify main domains of family quality of life and their indicators. Comparative analyses were used to examine differences between both type of participants.
Results: Topics about family quality of life were identified. Some of them accounted for family relationships, individual family members’ well-being, family resources, or context surrounding family life. Both type of perspectives differed in specific indicators.
Discussion: Results suggest the importance of addressing family quality of life by acknowledging the differences between primary caregivers and non-primary caregiver family members’ experiences. From a family-centered approach, professionals should align the different family member’s goals and needs in order to provide supports to family with the aim of enhancing its quality of life.
461 Goal attainment in the child-in-context-intervention (CICI): an individualized, goal-oriented intervention for children with acquired brain injury and their families
Ingvil Laberg Holthea,b, Nina Rohrer-Baumgartnera, Edel Jannecke Svendsena,c, Ida Borgena,d, Jens Egelandb,e, Shari Wadef,g, Cecilie Røed,h,i
aDepartment of Research, Sunnaas Rehabilitation Hospital, Nesodden, Norway, bDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway, cDepartment of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway, dDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, eDepartment of Research, Vestfold Hospital Trust, Tønsberg, Norway, fDivision of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA, gDepartment of Pediatrics, University of Cincinnati College of Medicine & Cincinnati Children’s Hospital Medical Center, Cincinnati, USA, hCenter for Habilitation and Rehabilitation Models and Services (CHARM), Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, iInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
ABSTRACT
Background: Children with acquired brain injury (ABI) may suffer long-lasting cognitive, emotional and social symptoms, affecting participation and everyday functioning. Nevertheless, there are few rehabilitation interventions that are evidence based and individualized, targeting these chronic symptoms at home and in school. The use of SMART goals (Specific, Measurable, Attainable, Relevant and Timely; 1) in such rehabilitation shows promise.
Aims: To describe the SMART goals of children with ABI in the chronic stage and their families, the level of goal attainment in the Child in Context Intervention (CICI) Study and to explore factors related to family, child and injury which may be associated with goal attainment.
Methods: The CICI is an individualized, goal-oriented telehealth intervention. Participating families are randomized 1:1 to intervention or treatment as usual. The intervention consists of seven video-conferenced family sessions, four video-conferenced meetings with the childrens school and one parent seminar with physical attendance. The families and children in the intervention group work on individualized SMART goals with rehabilitation specialists. In addition, strategies to manage the individual challenges are implemented in the children’s schools. Goal attainment is measured by Goal Attainment Scaling (GAS; 2).
Results: The ongoing CICI study will include 60 families, and inclusion will be finalized in October 2022. We have currently included 54 families. Goal attainment for the intervention group (n = 30, with an expected 3–5 goals per family) will be evaluated. The goal domains will be categorized in accordance with the International Classification of Functioning, Disability and Health (ICF). Goal attainment in different functional areas will be compared and indicators of goal attainment will be examined (e.g., parent educational level, time since injury, sex and age). Preliminary results will be presented at the conference.
Conclusion: Exploration of SMART goals and goal attainment levels from the CICI-study will shed light on the efficacy of CICI for improving meaningful, personalized goals for children in the chronic phase of rehabilitation after ABI.
1. Bovend’Eerdt, T. J., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clin Rehabil, 23(4), 352–361. https://doi.org/10.1177/0269215508101741
2. Turner-Stokes, L. (2009). Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clinical Rehabilitation, 23(4), 362–370. https://doi.org/10.1177/0269215508101742
462 Functional magnetic resonance imaging of working memory following mild traumatic brain injury versus concussion: a pilot study
Sarah McCabea, Jen-Kai Chena,b, Ekaterina Lunkovaa, Alain Ptitoa,b, Rajeet Salujaa,c
aDepartment of Neurology and Neurosurgery, McGill University, Montreal, Canada, bMontreal Neurological Institute, Montreal, Canada, cThe Research Institute of the McGill University Health Center, Montreal, Canada
ABSTRACT
The terms mild traumatic brain injury (mTBI) and concussion are often used interchangeably. The lack of a uniform definition for each term, however, creates confusion and controversies between patients, clinicians, and scientists. In the concussion definition, developed by the Concussion in Sport Group (CISG), patients do not need to present with one of the objective clinical signs after head injury (e.g., loss of consciousness), but instead only post-concussive symptoms (PCS), whereas in the mTBI definition created by the World Health Organization (WHO), they are essential. It is challenging to diagnose individuals when PCS are present but hallmark features of mTBI are absent, and this has given rise to incorrect diagnoses and inconsistent management strategies. We therefore implemented task-based functional magnetic resonance imaging (fMRI) to determine if mTBI and concussion are distinct diagnostic entities or if they should be considered as one. Regional brain activations were acquired using blood-oxygen-level-dependent (BOLD) fMRI from patients who fit the diagnostic criteria of mTBI as defined by the WHO, patients who fit the CISG definition of concussion without the WHO mTBI criteria, and matched controls. The patients were symptomatic and were recruited from a Level-1 trauma center within one month of injury. Using a working memory task previously validated by our group, we compared task performance and task-related BOLD signal changes between groups. Our results showed differences in fMRI activation patterns in both concussion and mTBI groups when compared to controls, despite performing as well as controls on the task. In general, patient in both groups presented with abnormal activations in our regions of interest, but these atypical activation patterns could not be attributed to post-concussion symptom scale score (PCSS) as linear regressions showed no correlations between BOLD signal changes and PCSS. Moreover, differences in fMRI activation patterns were seen between the concussion and the mTBI group, suggesting that the groups may be recruiting different brain regions to use in compensatory mechanisms when completing the task. Thus, while there are functional abnormalities seen in concussion, these alterations are not the same as those seen in mTBI, revealing that it may not be appropriate to combine these two entities under one banner. As access to services and treatment plans differ based on the diagnosis given, these results will likely have key clinical and research implications. Taken together, this study deepens our understanding of mTBI and concussion, with the goal of solidifying the diagnostic processes of these injuries across disciplines.
463 Mild traumatic brain injury exposure and associations with later life brain structure and memory performance in a sample of vietnam war veterans
Holly Echlina, Dale Stevensa, Gary Turnera, Magdalena Wojtowicza
aYork University, Toronto, Canada
ABSTRACT
Some evidence suggests that past exposure to mild traumatic brain injury (mTBI) and concussion may be associated with cognitive and neurological outcomes later in life. This study examined the potential impact of mTBI history on later life brain structure and functioning in a sample of Vietnam War veterans.
Methods: Participants were 47 veterans with mTBI exposures (Mage = 69.43, SD = 5.02) and 82 veterans without mTBIs (Mage = 68.51, SD = 4.69). These data were obtained from the Alzheimer’s Disease Neuroimaging Initiative – Department of Defense (ADNI-DOD) database. Participants’ average time since their first injury was 49.53 years and 47.28 since their most recent injury. Associations between mTBI, age, education, cognitive status, PTSD symptoms, delayed memory performance, subcortical volumes, cortical thickness, and white matter hyperintensity volumes were examined in brain regions implicated in AD and aging. Regression models were used to examine relationships between those with and without an mTBI history and cortical thickness of the entorhinal, posterior cingulate, temporopolar, inferior parietal, inferior frontal, and lateral temporal cortices and subcortical volumes of the amygdala and hippocampus (Sabuncu et al., 2011). Age, education, Montreal Cognitive Assessment (MoCA) scores, and lifetime scores on the Clinician Administered PTSD Scale (CAPS) were included in analyses.
Results: Older age was associated with lower thickness in the right lateral temporal cortex (p = 0.001), left entorhinal cortex (p = 0.003), and left temporal pole (p = 0.028), while years of education was associated with greater cortical thickness in the right entorhinal cortex (p = 0.023). PTSD was not a significant predictor of brain regions. MTBI was a significant predictor of differences in cortical thickness for the left lateral temporal cortex (p = 0.050). Additional analyses for those with single mTBIs compared to multiple mTBI exposures revealed lower cortical thickness in the right poster cingulate (p = .023) and larger volumes in the right amygdala (p = 0.022) for the latter group. Age at first injury exposure was associated with cortical thickness in the right inferior frontal cortex, wherein older age of first exposure to mTBI was associated with lower right inferior frontal thickness (p = 0.043). MTBI exposure was not a predictor of delayed memory performance or white matter hyperintensity volumes (both p > 0.05).
Conclusions: These findings highlight that while most brain regions were not different between those with and without mTBI exposures, there were several cortical regions that were associated with lifetime mTBI exposure in disease-vulnerable brain structures (Sabuncu et al., 2011) in a sample of Vietnam War veterans. MTBI appears to be associated with some differences in brain structure that are present later in life for older adult veterans, beyond the effects of PTSD symptoms, education, cognitive status, and natural aging.
464 Evaluating the effectiveness of the concussion awareness training tool for women’s support workers in building awareness of, and responding to, intimate partner violence-caused brain injury
Blake Nicola, Shambhu Adhikaria, Alanna Shweda, Stephanie Ashtona, Denise Beatonb, Karen Masonc, Heather Gainfortha,d, Shelina Babulb, Paul van Donkelaara
aUniversity Of British Columbia, Kelowna, Canada, bBC Injury Research and Prevention Unit, Vancouver, Canada, cSupporting Survivors of Abuse and Brain Injury Through Research, Kelowna, Canada, dInternational Collaboration of Repair Discoveries, Vancouver, Canada
ABSTRACT
Violence against women is a major public health problem and a violation of women’s human rights. The World Health Organization says about one in three women will experience physical or sexual violence in their lifetime. Women who experience physical intimate partner violence (IPV) are at high risk of suffering a brain injury (BI) as part of the abuse due to head impacts and strangulation. Despite that, most women’s shelter workers are not aware of IPV-caused BI, can’t recognize signs and symptoms, and do not routinely screen or assess for it. This study sought to address that gap by developing a new module of the Concussion Awareness Training Tool (CATT) specifically focused on IPV-caused BI, and measuring its effectiveness in increasing awareness and knowledge, and in changing behavior among frontline staff. The CATT for Women’s Support Workers (WSW) is available in English and French, and is the first evidence-based, eLearning tool of its kind on the topic of BI from IPV. It takes 30 to 40 minutes to complete and is designed to standardize prevention, recognition, diagnosis and management of concussions. We surveyed 81 women’s shelter workers from across Canada before and after they completed the CATT for Women’s Support Workers (WSW) training. Six months later, we interviewed a subset of nine participants to better understand what effect the training had on their daily practice supporting women survivors. The results demonstrate a significant increase in knowledge among participants – (p < 0.0001, effect size: 0.5) from the pre-survey (8.17 ± 1.1/12) to the post-survey (9.79 ± 1.8/12), as well as improvements in how they report advocating for, and being mindful of, clients with IPV-caused BI. An analysis of the interviews highlighted 3 main themes that arose from the module: knowledge, mindfulness, and advocacy. All participants felt their awareness and knowledge of IPV-caused BIs had increased as a result of the CATT WSW module, and said they would recommend the training to their colleagues. Ultimately, this online training may help improve the immediate care and referrals women with IPV-caused BI receive, and lead to increases in their overall quality of life.
465 Multi-disciplinary team perspectives on neuropsychological care and provision: a survey of staff within community neurorehabilitation teams in south west london integrated care board, UK
Cliodhna Carrolla, Shai Betteridgeb
aSouth West London Integrated Care Board, London, United Kingdom, bSt George’s Hospital, London, United Kingdom
ABSTRACT
Clinical neuropsychology is recommended within neurorehabilitation multi-disciplinary teams (MDT). There has been poor implementation of this recommendation. Guidance proposes a psychological stepped care model with all MDT members expected to support patients’ neuropsychological needs. There is a shortage of adequate training and support to complete this. A survey of staff within community neurorehabilitation team (CNTs) in South West London (SWL) Integrated Care Board (ICB) was completed to identify staff’s knowledge and confidence in addressing a range of neuropsychological factors and to explore staff views on neuropsychology. Respondents were asked to self-rate their knowledge and confidence in identifying and supporting patients with mood, adjustment and cognitive issues, from 0 (no knowledge/confidence) to 100 (most knowledge/confidence). They were also asked to consider neuropsychology provision in CNTs. Twenty-two staff members completed and returned the survey (c.20% response rate). Respondents were from across MDT disciplines and worked in neurorehabilitation between 1 and >20 years. Fifty-nine per cent of respondents (13/22) had neuropsychology provision in their current team. Respondents’ self-reported knowledge of identifying mood, adjustment and anxiety issues ranged from 0–100 (x = 71, 67 and 66 respectively) and confidence with these factors ranged from 0–100 (x = 71, 67 and 67 respectively). Self-rated knowledge of identifying risk issues ranged from 30–100 (x = 69) and confidence ranged from ranged from 30–100 (x = 68). Self-rated knowledge of supporting patients with mood, adjustment and anxiety issues ranged from 0–100 for mood and adjustment, and 30–100 for anxiety (x = 58, 56 and 62 respectively). Self-ratings for confidence of supporting patients with mood, adjustment and anxiety issues ranged from 0–100 for mood and 30–100 for adjustment and anxiety (x = 57, 57 and 31 respectively). Self-ratings of knowledge of identifying patients with cognitive issues ranged from 40–100 (x = 76) and supporting with cognitive issues ranged from 30–100 (x = 69); whilst confidence ranged from 30–100 (x = 75) for identifying issues and ranged from 0–100 (x = 69) with supporting with cognitive issues. The majority of staff endorsed provision of 1:1 psychotherapy with patients. Forty per cent of respondents endorsed neuropsychology to provide cognitive assessment and 50% endorsed cognitive rehabilitation and vocational rehabilitation. Group interventions for mood and adjustment, fatigue management, education about cognitive difficulties and cognitive rehabilitation strategies were endorsed by 80, 40, 50 and 40% of respondents respectively. Eighty per cent (16/20) endorsed staff training. The results from this survey suggest that some CNT staff do not have the knowledge and confidence required to provide psychological stepped care. There is a lack of robust understanding of the added benefit of clinical neuropsychology, beyond traditional psychological provision. Future work to provide psycho-education sessions to staff about the nature of neuropsychology and training in delivering neuropsychological care is indicated.
466 Social updating of character judgments in adults with chronic moderate-severe traumatic brain injury
Emily Morrowa,b,c, Michael Dulasd,e,f, Hillary Schwarbd,e,f, Neal Cohene,f, Melissa Duffa
aDepartment of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, USA, bDepartment of Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, USA, cCenter for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, USA, dBeckman Institute, University of Illinois at Urbana-Champaign, Urbana, USA, eDepartment of Psychology, University of Illinois at Urbana-Champaign, Urbana, USA, fInterdisciplinary Health Sciences Institute, University of Illinois at Urbana-Champaign, Urbana, USA
ABSTRACT
In a constantly changing environment, it is critical to make adaptive judgments as new information becomes available. For example, as we learn new information about the moral behaviors of others, we update our character judgments, which can profoundly shift how we think and act toward them. Past work by Croft and colleagues (2010) showed that focal damage to areas of the brain critical for emotional processing (ventromedial prefrontal cortex) and declarative memory (hippocampus) affect moral updating. Individuals with focal damage to ventromedial prefrontal cortex showed reduced change to their moral judgments in the presence of new information, whereas individuals with focal hippocampal damage showed heightened change. Given this pattern, the authors suggested that the prefrontal cortex contributes emotional salience to moral information, whereas the hippocampus provides important information to appropriately recall and contextualize moral judgments. Individuals with a history of moderate-severe traumatic brain injury (TBI) exhibit diffuse brain damage that often includes both the hippocampus and prefrontal cortex, and difficulty with flexible and adaptive behavior is also a hallmark deficit of TBI. However, there has been little investigation of how individuals with TBI make and update moral judgments about others. As a first step in this line of work, we asked 50 adults with a chronic (>6 months post-injury) history of moderate-severe TBI (27 F, mean age: 40.3 (SD: 11.0) years) and 50 demographically-matched neurotypical peers (27 F, mean age: 39.2 (SD: 10.9) years) to make moral judgments about static images of strangers, on a scale of 1 (very bad) to 7 (very good). Then, we presented a social scenario about that stranger that was morally positive, negative, or neutral and asked the participants to make another moral judgment. We hypothesized that TBI would disrupt the moral updating process. Participants with TBI made character judgments that were similar to neurotypical peers and in the anticipated direction of change following positive, negative, or neutral social scenarios. The judgments of participants with TBI, however, showed increased valence of change (e.g., more positive response to a positive scenario). At the group level, this pattern is more similar to individuals with declarative memory (hippocampal) impairment than individuals with emotional processing (ventromedial prefrontal cortex) impairment. There was also significant variability in the TBI group, raising the possibility of moral updating subgroups. Future work should determine if demographic or neuropsychological characteristics are associated with moral updating ability. Future studies should also examine how individuals with TBI integrate multiple pieces of new, consistent or conflicting, information about the moral behaviors of others. This work will inform the ongoing study of how people with TBI make decisions and adapt their behavior in response to changing information, which has significant implications for social participation and long-term outcomes.
467 Social work educator (SWE) views of the training and education needs of student social workers (SSW) in preparation for working with individuals and families affected by acquired brain injury (ABI)
Caroline Balda, Akudo Amadiegwub
aUniversity Of Essex, Colchester, United Kingdom, bUniversity of Essex, Colchester, United Kingdom
ABSTRACT
Social work education in the UK is governed by four regulatory bodies with no common curricula, with SWS’s in England alone undertaking multiple education routes in 82 higher education institutions (HEI). A growing body of evidence has demonstrated a potentially significant gap in ABI curricula inclusion in initial social work education. Little is known about the gap at a micro individual curriculum level or SWE’s views of ABI relevance in initial education. A UK-based NIHR funded project, Heads Together, is researching social work education curricula to evidence preparedness of graduating social workers for ABI practice and to develop resource database for curricula development. As part of the research project, a 12-point online survey was deployed to UK-based SWE’s with support of the Joint Universities Social Work Committee (JUSWEC) and the British Association of Social Workers (BASW). Of the 27 responses, thematic analysis of the data recognizes four key themes: 1) an acknowledged gap in ABI curricula inclusion in initial social work education including that of respondents; 2) significant numbers of respondents had personal experience of ABI (self, family or close friends); 3) majority view ABI should be mandatory part of initial social work education; and finally, 4) there are pockets of good practice often prompted by local practice. The survey findings will, in combination with interviewing newly qualified, specialist and commissioning social workers, inform curricula inclusion of ABI in social work education in the UK.
468 A hierarchical approach for the use of functional near-infrared spectroscopy to interrogate residual cognitive function in the intensive care unit
Karnig Kazaziana, Androu Abdalmalaka,b, Loretta Nortona,e, Sergio Novia,b, Reza Moulavi-Ardakania, Matthew Kolisnyka,b, Teneille E. Goftonc, Rickson C. Mesquitad, Adrian M. Owena,b, Derek Debickic
aWestern Institute of Neuroscience, Western University, London, Canada, bDepartment of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Canada, cDepartment of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Canada, d“Gleb Wataghin” Institute of Physics, University of Campinas, Campinas, Brazil, eKing’s University College at Western University, London, Canada
ABSTRACT
Introduction: Little is known about the extent of covert cognitive processing in acutely unresponsive patients in the intensive care unit (ICU). 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. To this end, our work aims to establish the validity of fNIRS as a tool for detecting the neural correlates of conscious processing in healthy participants and employ these methods to detect brain activity with acutely unresponsive patients in the ICU.
Method: A comprehensive and well-validated battery of neuroimaging paradigms was used to assess the reliability of fNIRS. The study consisted of four different tasks: (1) Resting state to assess functional connectivity (2) Median nerve stimulation to assess somatosensory perception. (3) Auditory stimuli to assess for lower-level and higher-order perceptual processing of sound and speech. (4) Motor imagery to assess for covert command following. The experimental protocol consisted of 2 study phases. In phase 1, we assessed the sensitivity of detecting brain activity in response to these paradigms with healthy controls. In phase 2, these same tasks were employed to assess residual cognitive function with one comatose patient (68 y/o, male) who sustained a brainstem stroke (Day 22, GCS = 6 T). 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: In healthy controls, all 24 participants had detectable resting-state activity in the default mode, somatosensory, auditory, and frontoparietal networks. For the somatosensory perception task, 17/17 (100%) of healthy controls showed activity in somatosensory areas. For the auditory processing task, 24/29 (83%) and 25/29 (86.2%) healthy participants demonstrated responses in the superior and medial temporal gyrus to the sound and speech perception contrasts, respectively. 22/24 (92%) healthy participants had responses in the premotor cortex or the inferior parietal lobule for the motor imagery task. When employed in the ICU with one patent, fNIRS responses revealed preserved somatosensory and auditory processing abilities. When asked to perform the motor imagery task, the patient showed consistent and reliable neural activity in predicted cortical areas. The patient also had all 4 resting-state networks preserved.
Conclusion: fNIRS results show high sensitivity for detecting brain activity for all tasks with healthy controls. fNIRS was successfully used to detect lower level and higher order cognitive function with one ICU patient. Importantly, the results demonstrate that the patient could willfully modulate his brain activity in response to commands, which suggests a level of awareness that was inconsistent with his clinical diagnosis. Future work will establish the clinical utility of fNIRS as a tool to detect conscious processing in patients with acute brain injuries.
469 Dynamics of synaptic damage in patients after traumatic brain injury
Florian Olde Heuvela, Zhenghui Lib, Shun Lia, Sandy R Schultzc, Patrick Öckla,d, Tobias M Böckersd,e, Cristina Morganti-Kossmanf, Bridgette Semplec, Francesco Rosellia,d,e
aDept. of Neurology, Ulm University, Ulm, Germany, bKaifeng Central Hospital, Kaifeng, China, cDept. of Neuroscience, Central Clinical School Monash University, Melbourne, Australia, dDZNE Ulm, Ulm, Germany, eInstitute of Anatomie and Cellbiology, Ulm University, Ulm, Germany, fDept. of Neurosurgery, The Alfred Hospital, Melbourne, Australia
ABSTRACT
Traumatic brain injury (TBI) is characterized by acute neuronal damage, vascular impairment and neuroinflammation. While a large component of the brain parenchyma is made of synapses, the extent of synaptic damage that occurs independent of neuronal loss remains unexplored. We aimed to investigate the time course of synaptic damage in cerebrospinal fluid of patients with severe TBI and determine the relationship between overall synaptic damage and clinical outcome.
We used the high-sensitivity SIMOA platform to quantify the levels of SNAP25, IL-6 and UCH-L1 in cerebrospinal fluid (CSF) samples from TBI patients (n = 42) between the day of injury (D0) up to discharge or catheter removal (between D5 and D12). A subset of these samples was subject to proteomic analysis to determine the concentration of 7 synaptic proteins (such as PSD-95, GriA4, MAP2). Cortical tissue samples obtained intraoperatively during neurosurgical intervention after TBI were used to quantify the transcription of 7 distinct synaptic proteins.
We found a strong elevation of SNAP25 at D0, with a rapid decrease from D3, but did not return to baseline in a subset of patients. This was followed by a secondary elevation from D7 in a subset of patients. SNAP25 concentrations did not correlate with GCS scores but a correlation was found between higher SNAP25 levels and worse GOSE outcome scores (GOSE 1–3). SNAP25 levels did not correlate with IL-6 levels but showed a significant positive correlation with UCH-L1 from D0 till D5. Proteomic analysis revealed distinct profiles across various synaptic proteins, with MAP2, PSD95, SPTBN1 and SPTAN1 peaking at D2-3, SNCA gradually increasing and peaking at D10, however GRIA4 progressively declining from onset with its lowest values at D10. Transcriptomics revealed a largely unmodified mRNA profile for several pre- and post-synaptic proteins.
Our data reveal that SNAP-25 levels in CSF are strongly affected by TBI, with temporal patterns only partially overlapping with those reflecting neuronal damage (UCH-L1) but not neuroinflammation (IL-6). Thus, synaptic damage seems to display a distinct path after TBI, indicating a specific pathophysiological mechanism, having a potential prognostic relevance. Our proteomic and transcriptomic data suggest that the release pattern in CSF after TBI may be different for different proteins and largely unrelated to transcriptional expression. Thus, markers of synaptic damage constitute a new potential for assessing the diagnosis and prognosis in patients with TBI.
470 Head control contributes to prediction of emergence from the minimally conscious state in children admitted to inpatient rehabilitation
Heather McLeana, Stacy Suskauera,b, Beth Slominea,b, Adrian Svingosa
aKennedy Krieger Institute, Baltimore, USA, bJohns Hopkins School of Medicine, Baltimore, USA
ABSTRACT
Children who sustain a brain injury and present in a disorder of consciousness (DOC) typically admit to inpatient rehabilitation with markedly limited functional motor skills. DOC includes the following: coma (state of unconsciousness without eye-opening), vegetative state/unresponsive wakefulness syndrome (VS/UWS; arousal/sleep-wake cycles without evidence of self- or environmental-awareness), and the minimally conscious state (MCS; discernable yet inconsistent evidence of consciousness). Pediatric physical therapists use the concepts of motor learning, developmental progression, and neuromotor reeducation when evaluating and treating these complex patients. Commonly used gross motor outcome measures may lack sensitivity in detecting small changes in this population. The Kennedy Krieger Institute created the Physical Abilities and Mobility Scale (PAMS) which does capture subtle changes and can supplement standard measures. Head and trunk control are considered key points for creating a stable postural foundation to promote the development of gross motor functional skills and mobility.
Objective: To examine the prognostic utility of the PAMS Head Control and Trunk Control items in predicting emergence from a minimally conscious state (MCS) among children with acquired brain injury admitting to inpatient rehabilitation in a DOC.
Design: Retrospective review of neuropsychology and physical therapy notes.
Participants: 40 patients aged 2–21 years in a DOC at the time of admission to an inpatient pediatric brain injury rehabilitation unit (first admission, directly from acute care).
Results: Patients admitting to inpatient rehabilitation in a vegetative state/unresponsive wakefulness syndrome were unlikely to emerge during the inpatient rehabilitation admission (NPV = 93.8%). Any independent head control ability (PAMS Head Control >1) at admission was associated with high likelihood of emergence (PPV = 81.8%), and all children who were able to maintain upright head control for >30 seconds at admission (n = 4) went on to emerge during the inpatient rehabilitation stay (PPV = 100%). Trunk control at admission did not significantly predict emergence. Combining information about state of consciousness as well as PAMS Head Control score, at admission, afforded strong overall prognostic value (AUC = 0.87, p < 0.001).
Conclusions: Though preliminary, results suggest that a brief measure of head control at admission to inpatient rehabilitation may supplement information about level of responsiveness to improve prediction of emergence from the MCS during the course of inpatient rehabilitation. Future work is needed to replicate study findings in an independent sample of children admitted for rehabilitation in a DOC.
471 TBI is associated with fast dc maturation and splenic immune modulation
Jin Zhanga, Markus Huber-Langb, Francesco Rosellia,c,d, Florian Olde Heuvela
aDept. of Neurology, Ulm University, Ulm, Germany, bInstitute of Clinical and Experimental Trauma-Immunology, University Hospital Ulm, Ulm, Germany, cDZNE Ulm, Ulm, Germany, dInstitute of Anatomy and Cellbiology, Ulm University, Ulm, Germany
ABSTRACT
Systemic inflammatory responses have been reported after traumatic brain injury (TBI), with almost all organs affected. The spleen, one of the most important immune regulatory organs, shows high interaction with the brain, known as the brain-spleen axis. Both brain-derived mediators as well as nerve fibers have been reported to directly affect immune cells in the spleen. We have previously investigated the effects of TBI on splenic immune cells, showing a fast maturation of splenic dendritic cells 3 h after an experimental TBI. However, how the inflammatory cytokine response changes to TBI, and possibly DC maturation, remains largely unknown.
We have performed transcriptional analysis of inflammatory cytokines and chemokines, fluorescent staining and in situ hybridization of spleen sections to investigate cellular mechanisms in immune cells 3 h post experimental TBI. In addition, we have performed large scale cytokine arrays to determine functional immune responses in spleen samples post TBI.
We found a significant FLT3/FLT3L upregulation 3 h post TBI. The FLT3L upregulation resulted in an enhanced phosphorylation of FLT3 in CD11c+ dendritic cells, which increased the protein synthesis and maturation process of dendritic cells, followed by an increased immunity. Experimental TBI resulted in a large-scale cytokine modulation. Out of which several were involved in vascular processes, shown by increase in Angiopoietin-1 and 2, MMP9. Other were involved in inflammatory T cell chemotaxis and activation, shown by the increase in CXCL1, CXCL9 and CXCL13. Furthermore, some were involved insulin regulation, shown by decrease if adiponectin and increase of IGFBP-1 and 2.
These findings indicates that there is a fast maturation and immunity of splenic dendritic cells upon TBI associated with FLT3/FLT3L signaling. Furthermore, this data suggests that TBI is regulating the production of cytokines involved in splenic immune, vascular, and metabolic processes. Showing the involvement of TBI on spleen functioning and its effect on systemic inflammatory responses.
472 The extent of special education and other educational support for children with acquired brain injury in the chronic stage – associations with cognition, brain injury symptoms and time since injury: findings from the child in context intervention (CICI) study
Edel Svendsena,b, Ingvil Laberg Holthea,c, Viljar Møretrøa,c, Maria Sandhaugd, Eli Marie Killie, Anine Pernille Strand-Saugnesf, Marianne Løvstada,c, Nina Rohrer-Baumgartnera
aDepartment of Research, Sunnaas Rehabilitation Hospital, Oslo 0495, Norway, bDepartment of Nursing and Health promotion, Oslo Metropolitan University, Oslo 0130, Norway, cDepartment of Psychology, Faculty of Social Sciences, University of Oslo, Oslo 0316, Norway, dThe National Committee on Medical and Health Research Ethics, The Norwegian National Research Ethics Committees, Oslo 0153, Norway, eDepartment of Profession Strategy and Knowledge Brokering, Statped: National Service for Special Needs Education, Holmestrand 3081, Norway, fDepartment of Aquired Brain Injury, Statped: National Service for Special Needs Education, 3081 Holmestrand, Norway
ABSTRACT
Background: Children with acquired brain injury (ABI) often have unmet educational and health care needs and are at risk of not receiving special education and other educational support in schools (e.g. concentration, support for problems with vision and having a quiet room to rest in if fatigued). ABIs are often under communicated over time in the school system, and special education and/or other educational support may be withdrawn over the years, without due assessment of needs. Moreover, many children with ABI with normal intellectual functioning do not receive sufficient services, even though they struggle at school due to brain injury symptoms and cognitive dysfunction that is less overt, such as headaches, fatigue and executive dysfunction.
Objectives: (1) To describe the amount of special education and other educational support of children with ABI in the chronic stage. (2) To explore the association between the extent of special education, other educational support, estimated intellectual functioning (WISC-V), parent-reported levels of brain injury symptoms, executive dysfunction as reported by parents and teachers, and time since injury in years.
Methods: Data from the baseline assessment of approximately 60 children and schools who participate in the Child in Context Intervention (CICI) Study will be analyzed. Inclusion criteria are: children aged 6–16 years, verified ABI diagnosis, at least one year since injury, attending school regularly, self- or parent-reported cognitive, emotional, behavioral and/or social challenges that affect every day functioning and/or participation, and the family is able and willing to participate actively in the CICI intervention and speaks Norwegian or English. The baseline assessment includes the Health and Behavior Inventory (HBI), the BRIEF-II completed by parents and teachers, subtests from the WISC-V and interviews with head masters/teachers about the child’s special education and other educational support. Inclusion of participants will end in October 2022, and results from the baseline data set will be presented. 54 families have been included so far.
Conclusion: Knowledge about special education, other educational support and their associations with intellectual functioning, brain injury symptoms, executive function and time since injury can help to identify factors that are associated with increased support at school and indicate whether children with ABI in the chronic stage are at risk of being underserved in the school system.
473 Implementation of an assistive technology for cognition within a community residence for adults with acquired brain injury to support meal preparation
Sareh Zarshenasa, Nathalie Bierb, Melanie Couturec, Emily Naldera, Sylvain Girouxc, Helene Pigotc, Mireille Gagnon-Royb, Guylaine LeDorezb, Nadia Gosselinb, Carolyn Lemskya, Carolina Bottari
aUniversity of Toronto, Toronto, Canada, bUniversity of Montreal, Montreal, Canada, cUniversity of Sherbrooke, Sherbrooke, Canada
ABSTRACT
Meal preparation is an essential activity for independent living that heavily draws on executive functions. Following acquired brain injury (ABI), individuals experience long-lasting executive and cognitive dysfunctions that may contribute to difficulties in the meal preparation process. In response to these needs, our team has been working on developing a Cognitive Orthosis for coOKing (COOK). This innovative technology is a web-based and context-aware system developed via a user-centered design approach in a living lab context. This study sought to investigate the feasibility of implementing COOK within a supported community residence for individuals with severe ABI by (1) examining the effect of using COOK on independence and safety in meal preparation and (2) exploring the perspectives of individuals with ABI and their care providers regarding the benefits, barriers, and facilitators of implementing COOK within the residence.
Methods: Using a mixed-methods approach, a multiple baseline single-case experimental design and a descriptive qualitative study were conducted. Of four candidates at the residence, a 47-year-old woman with a severe stroke met our inclusion criteria regarding cognitive and executive dysfunctions and the level of independence in the eight instrumental activities of daily living (IADL) using the IADL profile and was recruited ten years post-injury. At the time of the study, she lived in a shared apartment unit with all amenities while receiving 24/7 support from staff. She received 21 sessions of training on using COOK within a shared kitchen space. During meal preparation, independence and safety were evaluated using target behaviors: required assistance, task performance errors, and appropriate responses to safety issues, which were compared with an untrained control task, making a budget. Changes in target behaviors were assessed multiple times at baseline (before using COOK), during COOK training and adaptation, and follow-up phases. Further, the benefits, barriers, and facilitators of implementing COOK were investigated via individual interviews with the client and focus groups with the care team completed at three phases of the study.
Results: Findings showed that COOK significantly increased independence (90% CI = −1.0, −0.3) and safety (90% CI = −1.0, −0.3) during meal preparation, compared to the control task. Care providers suggested that providing a training toolkit for all staff, installation of COOK within the client’s apartment instead of a shared space, and availability of technical support would help successfully implement this technology in the long term.
Conclusion: COOK is a promising technology to increase independence and safety in meal preparation for clients with ABI within supported living contexts. However, due to the variation of ABI individuals’ needs, our team is currently working on developing the expert interface where therapists will have the possibility of personalizing the types and levels of cognitive assistance provided by the technology’s prompts to expand the usefulness of this technology.
474 Efficacy of rTMS in improving memory in older adults with TBI
Maheen Adamsona,b,c, Emily Dennisd, Victoria Liou-Johnsona,f, Michael Zeinehe, Xiaojian Kanga,c
aRehabilitation Service, VA Palo Alto, Palo Alto, USA, bNeurosurgery, Stanford University School of Medicine, Stanford, USA, cWRIISC-WOMEN/VA Palo Alto Healthcare System, Palo Alto, USA, dUniversity of Utah, Salt Lake, USA, eNeuroradiology, Stanford, USA, fClincial Excellence Research Center (CERC), Stanford School of Medicine, Stanford, USA
ABSTRACT
Traumatic Brain Injury (TBI) is a significant cause of mortality and disability. Cognitive impairment and dementia are also devastating outcomes of TBI. TMS is now a widely accepted noninvasive brain stimulation treatment and is an excellent candidate for the treatment of TBI-related symptoms. rTMS has also demonstrated memory benefits in older adults without threshold memory disorders with the left DLPFC as the most commonly used target for memory enhancement in healthy older adults. In a recently completed double-blind randomized clinical trial, we have enrolled (n = 30; 10 females) veterans and civilians (mild (n = 21) and moderate (n = 9) TBI; average age = 61 years) in either a placebo or an active trial arm. For both active and sham rTMS coils, pulses were delivered at 10 Hz in trains of 4 s followed by 11–26 s intertrain intervals, consistent with on-label parameters for depression treatment. We collected performance on a computerized hippocampally-mediated visual Paired Associate Learning (PAL) task at baseline and post-treatment along with MRI and PET imaging. No significant changes in PAL (average number of correct trials) were observed between active and sham pre and post-treatment. No differences were observed in fiber tracts between sham and active groups pre and post-rTMS treatment either. However, a preliminary analysis of gender effects showed greater FA reduction and medial diffusivity (MD) increment in the right cingulum hippocampus in women relative to men. Additionally, preliminary glucose uptake in PET analysis also showed a higher correlation of PAL trial score with higher hippocampal activity in the active group at post-treatment. These findings, although impacted by the drop in recruitment and follow-up due to the pandemic, highlight the use of neuroimaging in response to treatment in specific areas that may be crucial to monitor in older TBI patients.
475 From unresponsive wakefulness syndrome/vegetative state to consciousness: course and factors associated with recovery in children and adolescents
Monica Ferreaa, Maria Cecilia Gonzaleza, Florencia Giselle Leguizamona, Lara Dei Vecchia, Mauro Federico Andreua, María Flavia Dorregoa
aFleni, Escobar, Argentina
ABSTRACT
Introduction: Disorders of consciousness (DoC) are a common consequence of severe acquired brain injury. There is limited information regarding the course of recovery and outcome of pediatric population with DoC. These may be associated with variables, such as age at the time of injury, etiology, and time to admission to a rehabilitation program.
Objective: The purpose of this study was to estimate the rate and time to emerge from unresponsive wakefulness syndrome/vegetative state (UWS/VS) to consciousness and explore associated factors in children and adolescents with DoC.
Methods: In this observational, analytical and retrospective study we included children and adolescents in an inpatient neurological institute in Argentina. Clinical records between 2005 and 2021 were reviewed. Patients were admitted in UWS/VS secondary to traumatic brain injury (TBI) and non-traumatic brain injury (NTBI) and participated in a 12-week specialized rehabilitation program. Recovery of consciousness was defined as ≥ 44 points in the Western Neuro Sensory Stimulation Profile and sustained in at least three weekly consecutive assessments. Statistical analysis included univariate and multivariable Cox regression models. Age at the time of injury, sex, time to admission and etiology [divided into 3 categories: TBI, hypoxic-ischemic encephalopathy (HIE) and other NTBI (stroke, encephalitis, tumors)] were considered. Hazard ratios (HR) and their related 95% CIs were informed. Also, the median time to emerge and the Kaplan Meier curve were computed.
Results: Seventy patients [median age 8,6 (IQR 4,3–13,5) years; female 58.6%; median time to admission 2.2 (IQR 1.5–4.5) months] were finally included in the analysis. Nineteen (27.1%) patients emerged from UWS/VS to consciousness during the 12-week period. The median time to recovery of consciousness was 5 (IQR 4–7) weeks. In the multi-variable Cox regression model, being controlled by sex, age and time to admission, patients with HIE had significant less probability of emerging to conscious state in comparison with other NTBI (HR 0.22, 95% CI 0.05–0.08, p = 0.03). Patients with TBI did not significantly differ in terms of probability of emerging to conscious state in comparison with other NTBI (HR 0.72, 95% CI 0.24–2.17, p = 0.57).
Conclusions: Almost 30% of patients emerged from UWS/VS to consciousness during the 3-month follow-up. In the multivariate analysis HIE was the only factor independently associated with less probability of emerging to conscious state than other NTBI. Our results point to the impact of etiology on the recovery of this population and could inform treatment decisions in this emerging topic in the field of pediatric neurology.
476 Investigating the impact of neurologic music therapy on the spatiotemporal gait parameters and mood for adults and children who have an acquired brain injury
Shane Cassidya, Rebecca O’Connora, Hilary Mossa
aNational Rehabilitation Hospital, Dublin, Ireland, Dublin, Ireland, bUniversity of Limerick, Limerick, Ireland
ABSTRACT
Despite the body of research that demonstrates the effects of Neurologic Music Therapy (NMT) sensorimotor techniques for adults with neurological conditions, little is known about their impact on both adults and children living with an acquired brain injury (ABI). Furthermore, little attention is given to mood related sequalae in NMT research. The aim of this study is to assess the benefit of a combination of sensorimotor techniques to improve selected spatiotemporal gait parameters and mood of participants. The hypothesis is that it is possible to support both gait and mood for adults and children who had an acquired brain injury through NMT techniques and personally preferred music. Twelve participants in a rehabilitation hospital were recruited and assigned to a group within a multiple-baseline single case design. The three techniques, rhythmic auditory stimulation, patterned sensory enhancement and therapeutic instrumental music performance were used in each session. Weekly timed 10 m walk tests and mood scales were completed by participants. Participants’ perceptions were recorded in a survey post treatment, and video analysis was conducted by clinical specialists in ABI. Results from the quantitative aspect demonstrate significant increases in velocity and stride length. Effect size suggests a large reduction in anxiety. Findings from thematic analysis of participant feedback and video analysis reveal that music therapy may improve mood while enhancing gait speed and quality and may also increase motivation and engagement levels. Furthermore, findings highlight the unique goal areas that can be supported through NMT, particularly in relation to activities of daily living. Small sample size indicates further research is warranted. However, this study concludes that both gait and mood related goals may be supported through musical choice within NMT sensorimotor techniques.
477 Demographic and clinical characteristics of patients referred with persistent post-concussion symptoms after mild traumatic brain injury or minimal head injury
Linda Fordala,b, Alexander Olsenb,c, Simen Berg Saksvikb, Cathrine Elisabeth Einarsenb, Toril Skandsena,b
aDepartment of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway, bDepartment of Physical Medicine and Rehabilitation, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway, cDepartment of Psychology, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
ABSTRACT
Objective: Mild head injuries have been extensively researched in recent decades, resulting in important knowledge of their characteristics and trajectories. Nevertheless, we know less about the large group of head injuries typically not included in classification systems for head injuries: the minimal head injuries. In the current study we examine the demographic and clinical characteristics as well as symptoms reporting of patients with head injuries, referred to a specialist clinic due to persistent post-concussion symptoms (PCS) and categorize these into mild traumatic brain injury (MTBI) and minimal head injury (MHI), for further comparison.
Methods: Prospective longitudinal cohort study conducted at an outpatient specialist clinic for physical medicine and rehabilitation, at a university hospital in Norway. Participants (n = 103) were patients 16–65 years, referred July 2019- July 2022, with PCS occurring within a week and lasting > 2 weeks after an MTBI (head trauma with alteration of brain function/consciousness or other proof of externally caused brain pathology) or MHI (head trauma. MTBI criteria not fulfilled). Data were collected through a semi-structured interview. PCS was measured with the Rivermead Post-concussion symptoms Questionnaire (RPQ), global function with the Glasgow Outcome Scale Extended (GOSE).
Results: Forty-two percent had sustained an MHI and 58% an MTBI (mean age: 35.6/ 38.6 years, 72%/ 68% women, mean time from injury to inclusion:19.1/ 14.6 months). More MHI participants had a university/college degree (71% vs. 49%. p = 0.037). Regarding pre-injury factors, MHI participants more often reported a pre-injury headache problem (52% vs. 21%. p = 0.012). No other differences in pre-injury health or function were found. Regarding injury-related and post-injury factors, MHI participants sought health care later post-injury, measured in days (M/Md/SD: 4.2,1.0,10.4 vs. 2.0,0.0,4.9. p = 0.036), had a lower highest level of initial care (89.7% vs. 58.3% only saw a GP. p = 0.001) and more frequently had a low GOSE score (5 or 6) at the first consultation (90.7% vs. 74.1%. p = 0.035). Symptoms started immediately for most MHI/MTBI participants (65.9%/ 74.1%), and headaches were frequently reported at the first consultation (95.1/ 88.7%). There were high average RPQ total scores (MHI/MTBI:30.1/ 29.0), yet no statistically significant differences.
Conclusions: A considerable number of patients at a specialist clinic for persons with persistent PCS, had sustained an MHI, not meeting criteria for MTBI, yet few statistically significant differences between groups were found. However, the MHI group more often reported a pre-injury headache problem, had worse global functioning and were commonly seen solely by a GP, indicating a need for good clinical pathways for MHI and PCS in primary health care. A lack of current knowledge about MHI combined with a considerable number of health care-seeking MHI patients with persistent PCS, necessitates more research to ensure quality treatment.
478 A retrospective view of 100 patients with acquired brain and spinal cord injury in pediatric unit of national rehabilitation hospital
Muhammad Awaisa, Susan Finna,b, Irwin Gilla,c,d
aNational Rehabilitation Hospital, Dublin, Ireland, bChildren’s Health Ireland at Crumlin, Dublin, Ireland, cChildren’s Health Ireland at Temple Street, Dublin, Ireland, dSchool of Medicine, University College Dublin, Dublin, Ireland
ABSTRACT
Introduction: Epilepsy is commonly identified in children with rehabilitation needs. Seizures and antiepileptic medications have the potential to adversely affect children during rehabilitation admissions. We aimed to review the records of 100 consecutive patients admitted to a national tertiary rehabilitation center to examine the prevalence of epilepsy, the nature of prescribed treatments in this population, and the effect of seizures on rehabilitation admissions.
Methods: 100 consecutive admissions from September 2016 to July 2022 were identified on the service database, and medical records reviewed. Demographic information was collected, as well as information pertaining to epilepsy, anti-epileptic medications, and seizure incidence.
Results: 61 males and 39 females were admitted during the study period. Among girls age range was 3 months −17 years with mean age of 5 years. Boys age range was 1 year to 18 years with a mean age of 7 years. 88% of admissions had acquired brain injury and 12% had spinal cord injury (30% TBI, 17% ABI due to infection, 13% stroke, 13% brain tumor, 4% inflammatory ABI, 11% ABI of other cause, 6% traumatic SCI, 4% inflammatory SCI, 2% SCI of other cause). 26% of patients (12 boys, 14 girls) were known to have epilepsy; of these, 22 (84%) were on antiepileptic medications. Among these patients 16 out of 26 were prone to focal seizures, 8 to generalized tonic clonic seizures and 2 to absence seizures. Prescribed medications included Levetricetam (14), Lacosamide (3), lamotrigine (3), Rufinamide (3) and Brivaracetam (2). 3 patients (2 females and 1 male) were prescribed multiple medications (Lacosamide + Rufinamide). Six patients (3 boys & 3 girls) had documented seizures during admission. Two patients had a rehabilitation admission interrupted by seizures, due to need for outward transfer to a tertiary pediatric hospital.
Discussion: Epilepsy is common among children admitted for tertiary specialist rehabilitation in Ireland; admissions are rarely interrupted due to seizures, however. Most children with epilepsy were on prescribed medication, which has the potential to affect their cognition and behavior.
Conclusion: Effective monitoring for seizures is important in tertiary rehabilitation centers. The impact of epilepsy and anti-epileptic medications on rehabilitation should be considered by rehabilitation providers.
480 Integrity of non-motor skill learning following traumatic brain injury
Ryan McCurdya, Melissa Duffa, Natalie Covingtonb
aVanderbilt University, Nashville, USA, bUniversity of Minnesota, Minneapolis, USA
ABSTRACT
Memory is not unitary but consists of multiple anatomically and functionally distinct systems. Memory taxonomies include declarative memory (rapidly formed memories for episodes and facts) and non-declarative memory (incrementally formed memories for habits and cognitive and motoric skills). Declarative memory deficits are well documented following TBI, but little is known about the integrity of non-declarative memory beyond motor skill learning. Given that the success of many interdisciplinary rehabilitation programs rest on a patient’s ability to (re)learn skills and habits, there is a gap in the literature surrounding non-declarative memory performance in TBI. To fill this gap, we administered an established probabilistic learning paradigm to individuals with TBI. This task has been used previously to assess non-declarative learning in populations with relatively isolated declarative (hippocampal amnesia) or non-declarative (Parkinson’s Disease, Huntington’s Disease) memory impairments. 52 participants with chronic moderate-severe TBI and 52 non-injured comparison (NC) participants (group matched for age, sex, and education) completed the study. Participants completed 350 trials of the Weather Prediction Task, a measure of probabilistic cognitive skill learning, on a computer screen. In each trial of the task, participants were asked to predict one of two outcomes (rain or shine) based on a combination of four possible cues on the screen. Each cue set was associated with a fixed probability for either outcome. After the participant indicated their response, feedback on accuracy was given. Learning on the task is evidenced by increasingly accurate predictions over time. Consistent with prior research, we fit two logistic mixed-effect regression models: one modeling early learning and a second modeling late learning. Each model predicts the log-odds of a correct response per trial as a function of group, trial, and their two-way interaction. Random intercepts for trial configuration (i.e. which set of cues the participant was responding to), and random slopes by participant were included in the models. The first model (early learning) revealed a significant group by trial interaction effect. Relative to NCs, the TBI group demonstrated an attenuated increase per trial in probability of a correct response (B = −0.77, z = −2.53, p = 0.01). The second model (late learning) showed a significant effect of group, where the TBI group had a reduced likelihood of producing a correct response across trials. (B = −0.18, z = −2.59, p < 0.01). As a group, individuals with TBI learned the regularities of the probabilistic learning task more slowly than non-injured comparison participants. These results suggest that cognitive skill learning, and non-declarative memory are not uniformly spared following TBI. Clinical interventions which attempt to leverage non-declarative learning to compensate for declarative memory deficits may need judicious application based on an individual patient’s particular memory and learning profile for maximal effect.
481 Simultaneous coordination of multiple memory systems in adults with moderate-severe traumatic brain injury
Natalie Covingtona, Ryan McCurdyb, Neal Cohenc, Melissa Duffb
aUniversity of Minnesota, Minneapolis, USA, bVanderbilt University, Nashville, USA, cUniversity of Illinois Urbana-Champaign, Champaign, USA
ABSTRACT
Traumatic brain injury (TBI) results in heterogeneous deficits, including to multiple memory systems. Traditional memory taxonomies include declarative and procedural memory. Early studies sought to delineate differences between these memory systems and tasks were developed to index ability constrained to a particular system. “Process pure” assessments were critical for establishing multiple memory systems theory, but necessarily oversimplified memory function. Most human behaviors do not rely on a single memory system, but rather require the simultaneous coordination of multiple memory systems. Thus, there are increasing calls to investigate these interactions. There is a corresponding call to better characterize heterogeneity in cognitive profiles. Many individuals with TBI demonstrate impairments in declarative memory, and some demonstrate impairments in procedural memory. Across systems, there is significant inter-individual variability in presence and degree of memory impairment, suggesting that individual patients have unique deficit profiles that may impact recovery. A key question is how these differences in memory profile might influence performance on tasks that require coordination of memory systems. The mirror-reversed reading (MRR) task was developed to investigate multiple memory systems simultaneously in patients with amnesia. Participants read triads of mirror-reversed, low-frequency words. Healthy participants demonstrate procedural learning for the perceptual skill of reading reversed text, evidenced by increased reading speed over time. Additionally, a subset of MRR triads are repeated. Healthy adults demonstrate an additional speed benefit for repeated triads. In contrast, patients with amnesia demonstrate similar performance to healthy participants on the nonrepeating triads (preserved procedural memory), but significantly less benefit for repeated triads (disrupted declarative memory). Here, we examine performance on the mirror-reversed reading task in 57 patients with moderate-severe TBI and 57 demographically-matched noninjured comparison (NC) participants. A multilevel conditional growth curve model was fit to the MRR data to examine group differences in learning over time. The final model included fixed effects of Group (TBI vs. NC), Condition (novel vs. repeating triads), the growth term (Block), and their two-way interactions. The linear growth term was allowed to vary across participants and conditions. At the group level, individuals with TBI did not differ in their overall rate of learning compared to uninjured adults. There was a significant interaction between Condition and the growth term, with reading times decreasing more rapidly for the repeating relative to novel words (b = −2.1, p < 0.001). There was also a significant main effect of Group, with patients with TBI reading more slowly overall compared to uninjured participants (b = 4.2, p = 0.01). Despite a lack of group difference in overall learning rates, there was significant inter-individual variability. These findings suggest that the MRR task captures individual differences present in the coordination of multiple memory systems in TBI.
482 Change in concussion knowledge: evaluation of the concussion awareness training tool for youth
Heather A. Shepherda,b,c,d, Jean-Michel Galarneaua,b,c,d, Matthew Neilla,b,c,d, Shazya Karmalie, Kate Turcottee, Stephanie Cowlef, Alison Macphersong,h, Nick Reedi,j,k, Kathryn J Schneidera,b,c,l,m, Jeffrey G. Caronn,o, Kathy L. Beltonp, Isabelle J. Gagnonq,r, Amanda M. Blacka,b,c,d, Carolyn A. Emerya,b,c,d,s
aUniversity Of Calgary, Calgary, Canada, bAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, cHotchkiss Brain Institute, University of Calgary, Calgary, Canada, dO’Brien Institute for Public Health, University of Calgary, Calgary, Canada, eBC Injury Research and Prevention Unit, BC Children’s Hospital, Vancouver, Canada, fParachute, Toronto, Canada, gSchool of Kinesiology and Health Science, York University, Toronto, Canada, hLaMarsh Center for Child and Youth Research, York University, Toronto, Canada, iDepartment of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada, jRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, kBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, lSport Medicine Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, mEvidence Sport and Spine, Calgary, Canada, nSchool of Kinesiology and Physical Activity Sciences, Faculty of Medicine, Université de Montréal, Montreal, Canada, oCenter for Interdisciplinary Research in Rehabilitation, Montreal, Canada, pInjury Prevention Center, School of Public Health, University of Alberta, Edmonton, Canada, qSchool of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada, rDepartment of Pediatrics, Division of Pediatric Emergency Medicine, McGill University Health Center, Montreal, Canada, sDepartments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
ABSTRACT
Background: Concussion education is recommended to support concussion knowledge and behavior changes. The Concussion Awareness Training Tool (CATT) for Youth is a 40-minute e-learning concussion module developed for high school-aged youth.
Purpose: To evaluate the CATT for Youth by examining changes in general concussion knowledge and knowledge of concussion signs and symptoms in high school students (grades 10–12) in Calgary, Canada.
Methods: This study used a stepped-wedge trial design. High schools were randomly assigned to an intervention group or delayed intervention group. The intervention group completed a pretest then immediately following the pretest, completed the CATT for Youth. The intervention group completed a posttest two-to-six weeks following the CATT for Youth. The delayed intervention group completed a pretest, then two weeks later completed another pretest, and then immediately following the second pretest completed the CATT for Youth. The delayed intervention group completed a posttest two-to-six weeks following the CATT for Youth. The questions on the pre- and posttests were identical. A complete case analysis using a multilevel model with a flexible correlation structure accounting for sex, grade, group, concussion history, and weeks since entry into trial was conducted. A multilevel interval regression accounted for ceiling effects for the general concussion knowledge score.
Results: 471 participants (69% female; 29% history of concussion) participated in this study. There were five schools totaling 16 classes (n = 337) randomized to the intervention group and two schools totaling six classes (n = 134) randomized to the delayed intervention group. All 471 participants completed a pretest. The full model estimation showed mean general concussion knowledge pretest scores (Intervention = 6.83/8, delayed intervention = 6.33/8) increased following the CATT for Youth module by a mean change of 0.58 points (95% CI: 0.26–0.91). There was no heterogeneity between groups. Mean pretest scores for knowledge of signs and symptoms (Intervention = 11.19/15, delayed intervention = 10.54/15) did not improve on the posttest for either group. In the delayed group, no significant changes were observed for either general knowledge or signs and symptoms scores between pretests.
Conclusions: The CATT for Youth module improves general concussion knowledge in a high school-aged youth sample. Further research is needed to modify the CATT for Youth e-learning module content to improve changes in knowledge of concussion signs and symptoms. Additionally, further research exploring the association between concussion knowledge and concussion-related behaviors is needed.
483 Predictors of brain age gap among patients with traumatic brain injuries and healthy controls
Maheen Adamsona,b,c, John Coetzeee, Xiaojian Kanga,c, Ines Luttenbachera, Victoria Liou-Johnsona,h, Srija Seenivasani, Emily Dennisd,g, Frank Hillaryf
aRehabilitation Service, VA Palo Alto/Neurosurgery, Stanford University School of Medicine, Palo Alto, USA, bNeurosurgery, Stanford University School of Medicine, Palo Alto, USA, cWRIISC-WOMEN/VA Palo Alto healthcare System, Palo Alto, USA, dNeurology, University of Utah, Salt Lake, USA, ePsychiatry & Behavioral Sciences, Stanford School of Medicine, Palo Alto, USA, fPsychology, Pennsylvania State University, University Park, USA, gGeorge E. Wahlen Veterans Affairs Medical Center, Salt Lake, USA, hClinical Excellence Research Center (CERN), Stanford School of Medicine, Stanford, USA, iUniform Services University, Bethesda, USA
ABSTRACT
TBI is a risk factor for early dementia, suggesting accelerated brain aging. We employed the brainageR algorithm to acquire predicted brain age (pBA) in TBI patients and healthy controls (HC’s). We also assessed the relationship between brain age gap (BAg), defined as pBA – chronological age (CA), and other variables, including total intracranial volume (TICV), hippocampal volume (HV), and cortical thickness (CT). We recruited twenty-three healthy controls (HCs) and ninety-four patients with TBIs. All MRI data acquired at VAPAHCS. pBA’s were calculated from T1W images using brainageR for all. Nine participants excluded as outliers, leaving 85 TBI patients (23 F) and 23 HC’s (12 F). Pairwise comparisons used the Mann-Whitney U. Spearman’s rho correlations conducted within each group, followed by construction of regression models. TBI patients and HC’s did not differ on CA, pBA, HV, or BAg. They did differ on education (p = 0.012), PCL score (p = 0.023), CT (p = 0.002), left CT (p = 0.001), right CT (p = 0.005), and TICV (p = 0.023). Among TBI patients, BAg was correlated with: pBA (ρ = 0.517, p < 0.001), CT (ρ = −0.297, p = 0.006), left CT (ρ = −0.245, p = 0.024), right CT (ρ = −0.285, p = 0.008), HV (ρ = −0.234, p = 0.031), and right HV (ρ = −0.279, p = 0.010). Among HC’s, BAg was correlated with CA (ρ = −0.590, p = 0.031). A regression model to predict BAg among TBI patients found that the most predictive model (adj. R2 = 0.287, p < 0.001) included pBA (β = 0.433, p < 0.001) and right hippocampal volume (β = −0.246, p = 0.012). For a subset of TBI patients (n = 75) we had age at injury (AAI) and years since injury (YSI). Adding these terms found the most predictive model (adj. R2 = 0.991, p < 0.001) included pBA (β = 1.665, p < 0.001), AAI (β = −1.420, p = 0.012), and YSI (β = −1.550, p < 0.001). Adding demographics (sex, education) did not help. For HC’s, the most predictive model (adj. R2 = 0.619, p < 0.001) was one including CA (β = −0.739, p < 0.001), sex (β = −0.609, p < 0.001), and education (β = −0.343, p < 0.027). Although TBI patients and HC’s did not differ on BAg, predictors of of BAg did. Among TBI patients, BAg was associated with neuroanatomical variables, pBA, AAI, and YSI. For HC’s, BAg was associated with CA, sex, and education. This supports the view that BAg in TBI patients is a function of neuroanatomical changes resulting from injury, while in HC’s it is a function of normal aging.
484 Exploring the role of personality traits in symptom-burden and return to work one year after mild-to-moderate traumatic brain injury
Benedikte Madsena,b,c, Silje C. R. Furea,b, Cecilie Røea,b,c, Daniel Løked,e, Marianne Løvstadd,e, Nada Andelica,b, Emilie Isager Howea,c
aDepartment of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway, bResearch Center for Habilitation and Rehabilitation Models an Services (CHARM), Institute of Health and Society, University of Oslo, Oslo, Norway, cInstitute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway, dDepartment of Research, Sunnaas Rehabilitation Hospital Trust, Nesoddtangen, Norway, eInstitute of Psychology, University of Oslo, Oslo, Norway
ABSTRACT
Background: Approximately one third of patients with mild TBI (mTBI) experience symptoms that persist beyond 3 months. While specific personality traits have been implicated in the persistence of symptoms after mTBI, studies that assess the influence of personality on recovery are scarce. An improved understanding of the role of personality in recovery after mTBI is essential to optimize treatment of individuals who do not fully recover after injury.
Objectives: To assess the relationship between personality traits, persistent post-concussive symptoms (PPCS) and return to work (RTW) in patients with mild-to-moderate TBI.
Design and Methods: Eighty-seven participants who had sustained a mild-to-moderate TBI 8–12 weeks previously were included in this study. Self-reported symptoms and work status was assessed at baseline and 12 months follow-up. PPCS were measured with the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). The personality traits Neuroticism, Extraversion, Openness to experience, Agreeableness and Conscientiousness were measured by The NEO Five Factor Inventory (NEO-FFI-3). Outcomes were analyzed using multivariable linear regression models while controlling for gender, injury-related factors, work-related factors and depressive symptoms measured with The Patient Health Questionnaire (PHQ-9).
Results: Factors significantly associated with more PPCS at one year were: female sex (coef. 8.3, 95% CI 3.9 to 12.7, p < 0.01), personality traits Neuroticism (coef. 0.4, 95% CI 0.1 to 0.6, p < 0.01), Openness to experience (coef. 0.3, 95% CI 0.1 to 0.5, p < 0.01), and Conscientiousness (coef. 0.6, 95% CI 0.3 to 0.9, p < 0.01), extra-cranial injuries (coef. 4.5, 95% CI 0.3 to 8.8, p < 0.04) and depressive symptoms (coef. 1.1, 95% CI 0.6 to 1.6, p < 0.01), explaining 56% of the variance. Factors significantly associated with lower RTW at one year were: female sex (coef. −22.9, 95% CI −37.3 to −8.5, p < 0.01), personality traits Neuroticism (coef. −1.2, 95% CI −2.0 to −0.3, p < 0.01) and Conscientiousness (coef. −1.2, 95% CI −2.4 to −0.02, p < 0.05), explaining 24% of the variance. Controlling for PPCS showed a significant association with RTW (coef. −1.3, 95% CI −2.2 to −0.4, p < 0.01), leaving personality traits no longer significant and explaining more of the variance (33%).
Conclusion: The relationship between personality traits and RTW may be mediated via PPCS. The findings support the need for development of effective treatment preventing symptoms after TBI in vulnerable persons in order to enhance RTW. The findings furthermore emphasize the need for incorporating personality traits into our models of outcome following mild-to-moderate TBI.
485 What are the types and characteristics of community-based services used by persons with brain injury? Results of a provincial survey
Laura Langera,b, Judith Gargaroa, Ruth Wilcockc, Lauren Houghc, Mark Bayleya,d
aUniversity Health Network – Toronto Rehab, Toronto, Canada, bDalla Lana School of Public Health, The University of Toronto, Toronto, Canada, cOntario Brain Injury Association, Toronto, Canada, dFaculty of Medicine, The University of Toronto, Toronto, Canada
ABSTRACT
Background: Persons who live with an acquired brain injury (ABI) need to access supports across the lifespan. We know from previous research and from persons with lived experience that it is difficult to identify and access appropriate community-based services. In 2020, the Ontario Brain Injury Association (OBIA) launched a province-wide online survey, the Brain Injury Impact Study, a research project asking persons with a brain injury and their family members about their experiences living in the community and the services they accessed.
Objectives: To describe the types and characteristics of services that were accessed and determine which factors influenced access to community services for adults with ABI.
Methods: People with an ABI were surveyed by OBIA between 2020 and 2021 via the online platform QuestionPro. Data collected included demographic data, injury characteristics, living circumstances, employment status, interpersonal relationships, health care accessed since their injury and in the past year, and symptoms associated with their brain injury, including their impacts on daily life.
Results: 1,649 adults with an ABI completed at least some of the survey between 2020 and 2021. The majority, 836 (66%) were female, mean age 40.5 years (SD 277.1), 460 (28%) had their TBI before 18 years. Mean time from injury was 20.2 years (SD 17.1) for adult ABI onset cohort and 35.0 years (SD 33.1) for pediatric ABI onset cohort. Depression and anxiety were reported by most participants (85%) following their injury. Those with pediatric TBIs reported lower socio-economic status (SES) (p = 0.002) and were more likely to report criminal convictions than those with adult onset ABIs (p < 0.0001). Those with higher income were more likely to access services like neuropsychology, support groups and OHIP covered services (e.g., physiatrist or neurologist) than those with lower income levels (p = 0.028). Being involved in litigation also increased the likelihood of accessing a neuropsychologist (p < 0.0001). Though access to services did vary across the province, most people reported they accessed services that were within an hour’s drive of home.
Discussion: Persons with adult onset TBI have high incidence of mental health issues following injury. Those with childhood TBIs have lower SES than those with TBIs after 18 years and are less likely to access services such as neuropsychology than those with higher SES. Access to ABI-related services is related to income level and involvement of litigation. Most people reported they accessed services that were within an hour’s drive of home suggesting that services have to be considered local if they are to be used. These results can be utilized to better advocate for increased and equitable access to care and to support appropriate system care planning for community services for adults with an ABI in Ontario.
486 Multidisciplinary perspectives of stroke self-management: a need for approaches focused on social determinants of health
Riqiea Kitchensa, Amber Armsteada, Chih-Ying Lia, Hashem Shaltonia, Timothy Reistetterb, Monique Pappadisa
aUniversity of Texas Medical Branch, Galveston, USA, bUniversity of Texas Health Science Center San Antonio, San Antonio, USA
ABSTRACT
Background: Persons with stroke often have difficulty managing their health after stroke placing them at increased risk for readmission. The perspectives of clinicians specialized in stroke care is needed to facilitate tailoring of self-management programs across diverse populations with different individual, social, and environmental conditions. The purpose of this study was to explore barriers and facilitators to stroke self-management guiding future development of stroke self-management programs.
Methods: We used a qualitative descriptive study design to conduct ten semi-structured interviews via audio-recorded videoconferencing. We recruited and purposively sampled clinicians from an academic health science center with a comprehensive stroke center in the US. Multidisciplinary clinicians specialized in stroke were identified based on their profession (i.e., nurse/care manager, speech-language pathologist, occupational therapist, physical therapist, and physician). The interview guide focused on facilitators and barriers to stroke self-management. The audio recordings were professionally transcribed, coded using NVivo, and analyzed using thematic content analysis. Three independent coders reviewed and analyzed the transcripts.
Results: A multidisciplinary group of clinicians were included: nurse/care manager (n = 1), speech-language pathologist (n = 1), occupational therapists (n = 2), physical therapists (n = 2), and physicians (n = 4). Clinicians were diverse in race and ethnicity, age, years of experience, and clinical settings. Five overarching themes were identified in the interviews: 1) social determinants of health (SDoH) impact on stroke outcomes and self-management; 2) timely identification and management of comorbidities; 3) quality care through an interdisciplinary team approach; 4) holistic approach to support stroke self-management across the care continuum; and 5) continuous self-management education for persons with stroke and caregivers.
Conclusion: This study demonstrates that clinicians desire to work in interdisciplinary teams to provide quality, holistic care, while addressing SDoH and supporting the timely management of comorbidities. In addition, clinicians seek to facilitate stroke self-management and recovery following stroke and provide continual education to persons with stroke and their care partners. Future work should explore effective strategies for incorporating SDoH into everyday clinical practice and in self-management programs to reduce health inequities and improve outcomes for vulnerable populations with stroke.
487 The cerebellar cognitive affective syndrome: still an unrecognized diagnosis in daily practice
Jan Wiersmaa, Marije Wiegersmaa
aInteraktcontour, Arnhem, Nederland
ABSTRACT
In order to achieve a proper explanation of the psychopathology of cerebellar injury and to arrive at optimal treatment, making an accurate diagnosis is essential: the ‘need to know’ (Schmahmann, 1997). Therefore proper understanding of the functional neuroanatomy of the cerebellum is required. Although nowadays the Cerebellar Cognitive Affective Syndrome (CCAS) is quite well known within the field of brain damage research, in daily clinical practice it seems to be underestimated.
Clinicians are familiar with the motor dysfunctions, but are unfamiliar with the mental consequences of cerebellar injury (i.e. executive, memory, linguistic, visuospatial and neuropsychiatric impairments). As demonstrated in 2 case studies this can lead to a delay in finding the proper care and treatment, sometimes of several years: causing confusion and misunderstanding – with all the associated consequences, both personally and financially. In an evaluation of 13 patients with cerebellar injury (12 of whom had a cerebellar stroke, 1 of whom had a cerebellar tumor), it was assessed if at referral to Hersenz/InteraktContour, a long term counseling facility for patients in the chronic phase of brain damage in the Netherlands, the diagnosis of CCAS had been made or considered. In only one case had a neurologist considered the diagnosis of CCAS, but then rejected it based on neurocognitive findings – even though the behavior matched CCAS. This patient was referred to a psychiatrist, whom could not explain the pattern of complaints and behaviors.
Conclusion: CCAS is recognized insufficiently. For this reason an information leaflet will be made for general practitioners in the service area of InteraktContour. The goal is to recognize CCAS at an early stage and, if necessary, to timely refer to counseling and/or psycho-education.
489 Identifying risk factors for concussion in youth ice hockey players in the largest longitudinal cohort study in canadian youth ice hockey
Paul Eliasona,b,c,d, Jean-Michel Galarneaua, Isla Shilla,b,c,d, Ash Kolstada,b,c,d, Shelina Babule, Martin Mrazikf, Constance Lebrung, Brent Hagela,b,c,h,i, Carolyn Emerya,b,c,d,h,i
aSport Injury Prevention Research Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, bAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, cO’Brien Institute for Public Health, University of Calgary, Calgary, Canada, dHotchkiss Brain Institute, University of Calgary, Calgary, Canada, eBritish Columbia Injury Research and Prevention Unit, Faculty of Medicine, University of British Columbia, Vancouver, Canada, fFaculty of Education, University of Alberta, Edmonton, Canada, gFamily Medicine, Faculty of Medicine and Dentistry and Glen Sather Sport Medicine Clinic, University of Alberta, Edmonton, Canada, hCommunity Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada, iPediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
ABSTRACT
Background: Several risk factors associated with concussion have been identified in youth ice hockey previously but there is inconsistent evidence for some factors, including sex, which require further study.
Methods: Data were used from the largest Canadian youth ice study to date; a five-year prospective cohort which included 4419 male and female ice hockey players (totaling 6585 player-seasons) participating in Under-13 (ages 11–12), Under-15 (ages 13–14), and Under-18 (ages 15–17) age groups. A validated youth ice hockey injury surveillance system was utilized which included annual baseline questionnaires, injury data, and individual level exposure hours. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Crude concussion rates with 95% confidence intervals (CIs) adjusted for cluster by team were calculated for each age group. Further, a multiple multilevel Poisson regression analysis with a random effect at a team level and including multiple imputation of missing covariates examined several potential risk factors for concussion including body checking policy, age group, year of play (first, second, or third), level of play (elite/sub-elite), lifetime concussion history, sex, player weight, and position of play (forward, defense, goaltender) to estimate concussion incidence rate ratios (IRRs).
Results: The crude concussion rate in Under-13s was 1.82 concussions/1000 game-hours (95% CI: 1.44–2.30), 3.47/1000 game-hours (95% CI: 3.00–4.02) for Under-15s, and 3.61/1000 game-hours (95% CI: 3.06–4.27) for Under-18s. Based on the multiple multilevel Poisson regression analysis, female players (IRRFemale/Male = 1.72; 95% CI: 1.21–2.46) and players with a previous concussion history (IRR = 1.81; 95% CI: 1.51–2.17) had higher rates of game-related concussion. Policy disallowing body checking in games (IRR = 0.55; 95% CI: 0.41–0.73) and being a goaltender (IRRGoaltenders/Forwards = 0.64; 95% CI: 0.44–0.95) were protective against game-related concussion. No other factors were significantly associated with rates of concussion.
Conclusions: Using data from the largest Canadian youth ice hockey longitudinal cohort study to date, female players (despite policy disallowing body checking) and players with a concussion history had higher rates of concussion. Goaltenders and players who play in leagues where policy disallowed body checking had lower rates of concussion. Policy prohibiting body checking continues to be the most effective concussion prevention strategy in youth ice hockey. Future studies should examine why female players are at elevated risk of injury to inform injury prevention strategies.
490 Examining life adjustments and wellbeing of young adults who had brain injuries in childhood and received brainSTEPS services
Brenda Eagan-Johnsona, Rachel Hurb, Monica Vaccaroc, Erika Paed, Lynn Della, Kaitlyn Fentona, Vy Phungb, Elizabeth Boyleb
aBrainSTEPS Brain Injury School Consulting Program, Pittsburgh, USA, bJohns Hopkins University, IDEALS Institute, School of Education, Baltimore, USA, cBrain Injury Association of Pennsylvania, Chambersburg, USA, dPennsylvania Department of Health, Harrisburg, USA
ABSTRACT
Background: Research shows students who had pediatric traumatic brain injuries (TBI) experience challenges during school years and after high school (Anderson et al. 2011; Rivara et al., 2012). Fewer studies, however, explored the long-term effects of pediatric TBI on adult functioning and wellbeing (De Netto & McKinlay, 2020). This study sought to fill this gap by examining the adult life adjustment and wellbeing of young adults who had pediatric TBI and received the BrainSTEPS school consultation. We present the status of BrainSTEPS graduates’ adult life adjustment and wellbeing, accompanying norm data from non-TBI population when available. We then compare the outcomes by graduate gender, number of TBIs experienced (single versus multiple), and severity of the TBI (mild versus moderate/severe).
Method: We used 145 reports from BrainSTEPS (52.8% female) graduates and parents who responded to phone interviews from fall 2021 to spring 2022. Most graduates had a single injury (74.5%), mild TBI (83.4%), followed by moderate/severe TBI (12.4%), with majority of injuries occurring between ages 14–18. Survey questions included indicators of (1) post-secondary education and/or employment, (2) substance use, and (3) wellbeing measures including relationships with significant others (Sydney Psychosocial Reintegration Scale; Tate et al., 1999), independence and social integration (Community Integration Questionnaire; Willer et al. 1994), and Satisfaction with Life Scale (Diener et al., 1985).
Results: Post high school, participants attended a 4- or 5-year college (58.6%) and had full-time (19.3%) or part-time employment (36.6%). Females were more likely to attend 4-year college and males were more likely to have full-time job after high school. Females reported more communication, social-emotional, and physical/sensory challenges in post-secondary education. Participants who had moderate/severe TBI were more likely to have attended 2-year or career/technical school whereas those who had mild TBI were more likely to have attended 4-year college. About 22.8% of the participants reported past or current substance use, with greater likelihood for those with multiple injuries or moderate/severe TBI. Participants with moderate/severe TBI reported more difficulties with relationships, social skills, public behavior, lower life satisfaction, and less independence. Many of the results were comparable to adult life adjustment findings in general population.
Implications: This study helps inform school-based staff and medical and rehabilitation providers of the needs and vulnerabilities of young adults with pediatric TBIs. This population may benefit from ongoing monitoring and proactive education and training after experiencing a TBI to facilitate early identification of challenges and appropriate receipt of school-age supports and services to better prepare them for their transition into adulthood. Resources, such as trainings in cognitive-communication skills, social skills and substance abuse prevention as well as post high school follow up coaching services, should be tailored to address potential gender, number of TBI, and TBI severity vulnerabilities.
491 Change of global functional level in the first 5 years after aneurysmal subarachnoid hemorrhage
Tanja Karica, Angelika Sortebergb,c, Cecilie Røea,c, Tonje Haug Nordenmarka,c
aDepartment of Physical Medicine and Rehabilitation Oslo University Hospital, Oslo, Norway, bDepartment of Neurosurgery, Oslo University Hospital, Oslo, Norway, cInstitute of Clinical Medicine, University of Oslo, Oslo, Norway
ABSTRACT
Background and Aim: The consequences of aneurysmal subarachnoid hemorrhage(aSAH) on functional outcome may be long-lasting and up to 40% of patients are unable to return to work. Improving long-term functional outcome is therefore highly important, yet there is a lack of knowledge about predictors of which patients are at risk of functional deteriorations across longitudinal trajectories. Identification of predictors might help in applying the proper rehabilitation services and more effective use of resources. The aim of this study is to assess changes in functional level from one to five years after aSAH and the predictors for such changes.
Methods: Prospective, longitudinal cohort including all aSAH patients admitted to neuro- intermediate ward after securing of ruptured aneurysm in 2011 and 2012. Demographic and aSAH characteristics, emotional distress (Hopkins Symptom Checklist – HSCL 25) and neuropsychological assessment were conducted at baseline, 1-and 5 years follow up. Functional level at one and five years follow up was assessed by Glasgow Outcome Scale Extended (GOSE). Ordered logistic regression was used to examine weather difference in GOSE from one to five years (categorized as worse, stable, better) could be predicted by age, gender, education, World Federation of Neurosurgery Scale (WFNS) at discharge from neurosurgical department, need for VP shunt, comorbidity, new medical events in period between one and five years follow up, HSCL25, and results on neuropsychological tests.
Results: The median age at ictus of aSAH of the 101 participants was 54 years (25–74), 61% were women, 32% had >12 years of education, 58% of participants had more than one comorbidity diagnosis. The median WFNS when aSAH occurred was median 2 (1–5) and WFNS at discharge from neurosurgical department after securing of aneurysm was median 2 (1–4). GOSE one year post aSAH was median 6 (3–8). In multivariate ordered logistic regression analysis were comorbidity with more than one diagnosis, higher education and GOSE at one year statistically significant predictors. In best fitted model after reverse elimination procedure GOSE at one year and education remained statistically significant. Education longer than 12 years more than tripled (OR3,3) the chance for improvement of global functional outcome from worse to stable and from stable to better.
Conclusion: The results indicate that aSAH severity is not contributing to changes in functional level in the chronic phase. The impact of education on functional trajectories after aSAH needs to be further explored.
492 Optimizing brain health post traumatic brain injury: a hospital-based psycho-educational program promoting neuroprotective lifestyles
Eleonore Pr Bayena, Clementine Gourioua, Charlotte Dehollain Lucasa, Pascale Bruguièrea, Christine Picqa, Hélène Roberta, Bertrand Pichona, Lise Pronesti Philippeaua, Cindy Roussela, Agnès Weill-Chounlamountrya
aSorbonne Université (GRC24), APHP – Pitie-Salpêtrière hospital, Paris, France
ABSTRACT
Outcome after a traumatic brain injury (TBI) is multi-determined and depends on the interaction of factors, including injury severity, pre-injury (e.g. level of education) and post-injury factors (e.g. access to health care resources including neuro-cognitive rehabilitation, but also environmental factors such as family/socio-economic support, follow-up of comorbidity conditions, physical activity, healthy sleep and diet …). These modifiable risk and neuroprotective factors have an impact on brain health and on post-TBI outcomes. Yet, primary-secondary prevention regarding brain health modifiable factors remains insufficient during TBI care management.
Because detection and management of risk factors help to prevent neurodegeneration that participate to cognitive decline and clinical dementia, optimizing brain health has gained interest in the neuroscientific community. Recent research projects that up to 40% of dementia cases may be preventable by targeting modifiable risk factors such as regular physical activity, good sleep habits or prevention of TBI (Norton, Yaffe, Lancet Neurol 2014; Livingston Lancet 2017). Multidomain brain health prevention enable indeed protect cerebral reserve and strenghten cognitive reserve that further prevent cognitive decline (FINGER studies, 2021).
We describe here the building of a hospital-based psycho-educational program promoting brain health (i.e., a state of optimal cognitive, sensory, socio-emotional and behavioral functioning, WHO 2022): it includes raising awareness about neuroprotective lifestyles and managing modifiable risk factors for patients with TBI.
The brain health program takes place during the out-patient rehabilitation. It engages a transdisciplinary group of health professionals (neuroscientists, physicians, rehabilitation professionals) that educate patients about easy steps toward healthy lifestyles. The implementation includes 1) a medical interview about lifestyles and daily life environment (social support, physical activity, diet, sleep habits), and clinical check/follow-up of comorbidities distinct from the TBI (cardiometabolic/vascular diseases, epilepsia, mood, addictions, sensory loss); 2) a targeted customized psychoeducation regarding modifiable risk factors. This entails recommendations regarding: cognitive stimulation, Mediterranean diet, physical fitness, secondary prevention of TBI (sport accident, road safety), therapeutic observance for chronic comorbidity conditions, healthy sleep habits, the benefits of social interactions, follow-up of mood disorders, prevention of tabacco/drug/excessive alcohol intake.
The objective is to increase patients’/caregivers’ awareness about the importance of brain health across the lifespan, while bringing positive messages to empower them regarding simple do-able changes in their daily life activities.
The present program builds on successful outcomes of MyBrainRobbie, a French-US-Irish initiative of our group supported from the Global Brain Health Institute and the Alzheimer’s Association. MyBrainRobbie.org is a public health initiative (launched in 2019) that promotes brain health among children/teens thanks to videos, educational packs and public health outreach strategies (available in 7 langauges, free): VISIT http://www.mybrainrobbie.org. Acknowledgments: Global Brain Health Institute Brain Lawlor, Eoin Cotter, Victor Valcour, Kristine Yaffe, Laurent Cleret de Langavant; Alzheimer’s Association; Atlantic Institute.
493 What outcome domains “matter most” following traumatic brain injury: a synthesis of speech-language pathologist’s perspectives
Annie Grabowskia, Ryan McCurdyb, Natalie Covingtonc
aGillette Children’s Hospital, Saint Paul, USA, bVanderbilt University, Nashville, USA, cUniversity of Minnesota, Minneapolis, USA
ABSTRACT
Purpose: Outcome measures in traumatic brain injury (TBI) rehabilitation are used to evaluate progress in the clinic, and treatment efficacy in research. However, there can be mismatches between the cognitive impairments that commonly-used outcome measures assess and the degree to which outcomes in these domains are valued by stakeholders. As part of a larger study examining the perspectives of key stakeholders (adults with moderate-severe TBI, close caregivers, and experienced clinicians), we conducted a qualitative evaluation of “what matters most” to speech-language pathologists with significant experience assessing and treating cognition and communication in adults with TBI.
Method: 41 speech-language pathologists (SLPs) across the United States completed a two-part survey which included questions characterizing their clinical experience and an open-ended response section. The open-response section included questions designed to elicit measurable outcome domains in TBI rehabilitation. Open-ended responses were analyzed using qualitative thematic analysis.
Results: Results from the clinical experience section revealed that respondents had experience as SLPs averaging 14 years, with an average of 9.5 years of significant experience with TBI. Respondents worked in varied practice settings ranging from acute care to outpatient. Inductive qualitative analysis of the open-ended responses resulted in 61 outcome domains that were organized into three themes: Primary Impairments Following TBI (with 41 [100%] of 41 participants contributing to this theme), Changes to Activities and Participation (41 [100%]), and Process Factors in TBI Rehabilitation (40 [96%]). Outcome domains organized under the Primary Impairments following TBI theme included physical, cognitive, communication, and psychological impairments following TBI. Domains highlighted by SLPs within this theme are well-represented in many widely used outcome measures for TBI. Outcome domains organized under the Changes to Activities and Participation theme included descriptions of the cascading impacts of primary impairments in TBI on other aspects of life (e.g. independence, employment, ability to complete activities of daily living, quality of life). Lastly, outcome domains organized under the Process Factors in TBI Rehabilitation theme went beyond recognizing common impairments caused by TBI or how these impairments impact patients’ lives. Rather, these domains captured important factors considered by SLPs to impact the success of TBI rehabilitation (e.g. familial support, acceptance, treatment buy-in).
Conclusion: Many of the most frequently cited domains reported by SLPs (e.g. memory, attention, executive function) are captured in currently available outcome measures for TBI; however, some of the domains cited by SLPs are rarely or never captured by current outcome measures for TBI rehabilitation (e.g. acceptance, ease-effort, use of compensatory strategies). Future work will synthesize findings from the current study with perspectives of other key stakeholder groups (e.g. individuals with TBI and their families) to inform the development of new outcome measures.
494 Neuroendocrine healing after TBI during pregnancy
Alicia Eastesa
aWomen In Film And Television (WIFT,) Austin, Austin, USA
ABSTRACT
Logline: Liminal Space, a feature documentary film, exposes the healing potential of pregnancy and explores the intersection of maternal health and Traumatic Brain Injury research, where emerging neuroscience and the phenomenal power of pregnancy converge.
Synopsis: Filmmaker Alicia Eastes is on an investigative mission to explore her marvelous personal journey of physical and metaphysical healing after a coma in 2011, making her way through the Liminal Space between coma and consciousness, in the process of being born into motherhood.
Pregnancy – A catalyst for healing
On September 13, 2011, in the second week of a professional reentry into filmmaking, Alicia crashed her bike and fell into a coma for thirteen days. The standard western medical community gave her a grim prognosis, based on comparable cases, and foretold lifelong dependency on treatments for brain injury related complications. In her determined, defiant way, Alicia turned to alternative therapies, like acupuncture and yoga, which effectively brought her to full independence from the grips of the for-profit medical system. Five years later, in the summer of 2015, after a challenging journey to fulfill her dreams against the odds of getting married, completing her MFA in screenwriting, and beginning her career as a filmmaker in Austin, she got pregnant. During her pregnancy, Alicia felt better and better day by day and was inspired with an urgency to begin researching her experience to document what she knew would be an unusual account.
Burgeoning Science
In her early research, she confirmed that her pregnancy was, in fact, responsible for her experience of healing. Through development and researching for this documentary project, she’s found further confirmation of her hypothesis and can’t wait to share her testimony of the regenerative superpower of female reproduction. In interviews with medical experts, scientific researchers, philosophical and spiritual authorities, she’s investigating through her personal experience the power of the body to heal and hopes to shed light for the medical community at large to benefit from her exploration of consciousness. Human Growth Hormone (HGH) is the only known organic substance that will regenerate damaged neuron tissues, and it surges through the mother’s blood stream during pregnancy. In addition to HGH, stem cells and other fresh, vital baby making processes go to work to repair damage within the mother and fit her for the demanding job of caring for an infant. The evolutionary restorative power of pregnancy is powerful. Alicia will tell this story from her own perspective and document her own investigation into the mystery of how her memory, balance, and personal identity was restored by her pregnancy and becoming a mother. Two interviews have been collected so far, one of Alicia, by her creative producer, and one with Dr. Eben Alexander.
495 Traumatic brain injury impairs relational memory across domains
Michael Dulasa,b, Hillary Schwarba,b, Emily Morrowd, Nirav Pateld, Nathaniel Boutonb, Neal Cohena,c, Melissa Duffd
aBeckman Institute: University of Illinois – Urbana-Champaign, Urbana, USA, bDepartment of Psychology: University of Illinois – Urbana-Champaign, Champaign, USA, cInterdisciplinary Health Sciences Institute: University of Illinois at Urbana-Champaign, Urbana, USA, dDepartment of Hearing and Speech Sciences: Vanderbilt University Medical Center, Nashville, USA
ABSTRACT
Traumatic brain injury (TBI) results in a host of cognitive impairments, with memory complaints being among the most common. Recent work suggests that TBI may result in particular impairments to hippocampally-mediated relational memory, i.e., the ability to bind together information in memory and to retrieve/use these relational representations in service of ongoing behavior. The extent and breadth of these impairments, however, is still unknown. Hippocampal dysfunction has been shown to impair relational memory across domains, including spatial, temporal, and associative memory. Thus, if hippocampal dysfunction underlies relational memory impairments in TBI, such deficits should be ubiquitous, regardless of the relational memory domain being tested. The present study assessed whether individuals with moderate-severe TBI show domain-general memory impairments relative to neurotypical comparison (NC) participants by testing memory for spatial information, temporal order, group membership, as well as simple item recognition. In this experiment, participants studied triplets of abstract, visually distinct items. At the beginning of each study block, participants were cued to attend to a particular domain: Item (Remember these items), Space (Remember where each item is shown), Order (Remember the order of the items), and Group (Remember which items are grouped together). These tasks were separated into blocks, and in each block, eight triplets were studied twice each and then memory was immediately tested. At test, participants were again shown eight triplets and answered a yes/no question about each triplet that was consistent with the domain that had been cued at study: Item (Did you see these items before?), Space (Were these items in these locations?), Order (Were these items shown in this order?), and Group (Were these items shown together?). Participants had unlimited time to respond either “Yes” or “No” to the test questions. Across all blocks, half of the test trials were intact triplets (i.e., “Yes” response). A Group (TBI, NC) x Domain (Item, Group, Order, Space) repeated measures ANOVA showed main effects of both Group and Domain, with no significant interaction. Individuals with TBI were impaired across domains, with both participant groups doing best on the Item task, and worst on the Group task. Individual differences in performance were significantly correlated across all domains within each group, suggesting a shared underlying mechanism, i.e., hippocampal relational memory. Thus, the present results demonstrate that TBI results in ubiquitous relational memory impairments, likely tied to dysfunction in the hippocampus and/or its interactions with other regions/processes. Further, as these impairments were seen when participants learned just a handful of items over a short time span, relational memory dysfunction may underlie other on-line, behavioral impairments seen in TBI, making it an important target for future research and intervention work.
496 Predicting good functional recovery in critically ill brain-injured patients using resting-state fMRI
Loretta Nortona,b,c, Karnig Kazazianb, Matthew Kolisnykb, Teneille Goftonc, Derek Debickic, Karina Regod, Adrian Owenb
aKings University College at Western University, London, Canada, bWestern Institute of Neuroscience, Western University, London, Canada, cDepartment of Clinical Neurological Sciences, Schulich School of Medicine, Western University, London, Canada, dUniversity of Toronto, Toronto, Canada
ABSTRACT
Purpose: Predicting functional recovery in patients who have sustained a severe brain injury is a substantial clinical challenge. Resting-state fMRI (rs-fMRI), which is a method of functional magnetic resonance imaging (fMRI), may be of use in this regard by evaluating network connectivity within the brain. Functional connectivity may serve as an objective measure of cortical integrity in unresponsive critically ill patients. In this work, we evaluated the prognostic utility of rs-fMRI in predicting functional recovery.
Materials and Methods: A 5.5-minute rs-fMRI sequence was acquired in 24 acutely comatose patients. We extracted ten canonical resting state networks from these patients, where spatial correlation to standardized templates indexed the cortical integrity of these networks. Several machine learning algorithms were used to map spatial correlations across these networks to predict a patient’s best neurologic outcome up to 6 months following injury. A good functional outcome was a score of 4 or 5 on the Glasgow Outcome Scale, whereas poor functional outcome was considered to be a score of 3 or lower.
Results: This approach could predict good functional outcome (9/11 patients correctly identified) versus poor outcome (11/13 patients). The right frontoparietal and left frontoparietal, medial visual, and default mode networks (DMN) were the strongest predictor of functional outcome. Clinical behavioral indicators did not improve the algorithms’ performance but assisted in decreasing variance in performance.
Conclusion: Rs-fMRI measures predicted the recovery of consciousness and good functional outcome with a higher sensitivity (83%) than traditional prognostic measures. Multiple resting state networks, rather than the previous exclusive examination of the DMN, should be used to inform acute cortical integrity to predict subsequent recovery.
Clinical Relevance: Indeterminate prognosis may lead to clinical uncertainty and impact medical decisions regarding life-sustaining care. Rs-fMRI may complement current clinical tools by identifying patients who will have a good recovery.
497 Impaired relational memory, but not contextual rule learning in adults with moderate-severe TBI
Hillary Schwarba,b, Michael R. Dulasa,c, Nathaniel A. Boutonc, Nirav N. Pateld, Neal J. Cohenb,c, Melissa C. Duffd
aBeckman Institute for Advanced Science and Technology, Urbana, USA, bInterdisciplinary Health Sciences Institute, Urbana, USA, cDepartment of Psychology, Urbana, USA, dSpeech and Hearing Sciences, Nashville, USA
ABSTRACT
Background: The ability to flexibly react to and act upon our world is a hallmark of cognition in everyday life. Deficits in flexible, goal directed behavior are a characteristic impairment following traumatic brain injury (TBI) and are often attributed to prefrontal cortex (PFC) dysfunction. While the ability to generate, update, and integrate information to meet current goals (flexible cognition) has traditionally been tied to PFC-mediated executive processes, we propose that the contributing role of the PFC depends on its interactions with the hippocampal relational memory system. In this experiment, individuals with and without TBI completed a context-dependent relational memory task that tested dissociable processes: 1) the formation of overlapping relational associations (relational memory; previously tied to hippocampal function); and 2) the flexible use of learned, context-dependent regularities (contextual rule learning; previously tied to ventromedial PFC and its connections with the medial temporal lobes). Relative impaired and spared behavioral and eye-tracking performance was assessed.
Method: 36 participants with moderate-severe TBI and 36 demographically matched neurotypical comparison (NC) participants completed this study. In our task, participants studied face-room pairs in each of two distinctly colored buildings. Each face appeared in a unique room of each building. Face-room pairs were assigned based on an underlying rule structure (females on the left and males on the right in one building, females on the right and males on the left in the other), though participants were not told about this rule. At test, participants were first shown a target face, followed by a gray-building (no-context phase). The building then changed to one of the two colors (context-phase), and participants were permitted to place the face back in its studied room for that context. Critically, novel faces were included, to permit a measure of rule learning, and participants were told to place these faces where they thought they fit best.
Results: Participants with TBI were significantly impaired compared to NC participants on placing the faces back in their associated rooms (relational memory), but did not perform significantly differently from NC participants when placing the novel faces on the context-appropriate side of each building (contextual rule learning). Study time eye-tracking data revealed that viewing behavior did not differ between the groups. However, test-time data showed that participants with TBI, in the absence of context information, were less likely to visually consider both possible rooms associated with a given face and instead, spend time looking at only one of the two associated rooms. These data suggest that memory representations may be less flexible for individuals with TBI.
Conclusions: Together, these behavioral and eye-tracking data indicate that TBI participants are impaired at updating and integrating overlapping information to meet current task goals, processes that depend critically on the hippocampus.
498 Teaching educators about acquired brain injury: improvements in knowledge and attitudes through an online professional development module
Shannon Scratcha, Sara Marshalla, Brendan Lama, Andrea Hicklinga
aHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
ABSTRACT
Background: Acquired Brain Injury (ABI) is the leading cause of death and disability among young children and can result in persisting cognitive, physical, behavioral, and emotional difficulties. However, many educators have limited or only some knowledge of ABI and its consequences for a student in the classroom. In Ontario, Canada, ABI is not an identified exceptionality in the education system, creating a barrier for the identification and support of students with ABI. Our previous research found limited ABI resources online for educators, and as such we developed an online professional development module, Teach-ABI. The module takes a case-based approach and defines ABI, reviews ABI symptoms and how they may affect learning and behavior, and outlines practical strategies educators can use to support students with ABI in the classroom. This abstract focuses on the impact of Teach-ABI on teachers’ knowledge and attitudes about supporting students with ABI in the classroom.
Method: 50 teachers from Ontario public and private schools took part in this pilot study over Zoom. Participants completed a set of surveys (ABI knowledge questionnaire, knowledge application case study, self-efficacy questionnaire) at three time points: before completing the module (T1), immediately post-module (T2), and 60 days after completing the module (T3). 29 participants also participated in a semi-structured interview about their experience completing the Teach-ABI module (content, resources, format) and reflected on their knowledge, practice, and attitudes. Through deductive content analysis, concepts related to participants’ knowledge and attitudes were examined, and salient quotes related to these outcomes of interest were extracted.
Results: Participants’ knowledge (i.e., correct answers to questions about ABI signs and symptoms) increased significantly from T1 to T2 (Z = −1, p < 0.001) and this knowledge change was maintained at two-month follow-up (T1 to T3 (Z = −1.5, p < 0.01)). No differences in knowledge was found between T2 and T3. Salient quotes support these findings, with participants expressing their realization of their lack of ABI knowledge, that the module content was relevant for their teaching, that the external resources included in the module were helpful, and that they will now consider ABI when supporting students experiencing challenges. Minor changes within the module were also suggested for future implementation including developing additional case studies and testimonies, and improving one aspect of functionality (the “read to me” feature).
Implications: Results from this exciting pilot are encouraging and indicate that the Teach-ABI online professional development module has a lasting, positive impact on educators’ ABI knowledge and attitudes toward students. We aim to make these resources accessible to educators in Ontario and elsewhere to improve outcomes and classroom experiences for students with ABI.
500 Adult athletes and the impact of psychological and sociological factors in prolonged symptoms after sport-related concussion
Vicki Wonga, Matthew Holahana
aCarleton University, Ottawa, Canada
ABSTRACT
Introduction: Psychosocial impairments in adult athletes with prolonged concussion symptoms are less evaluated in the course to return to play (RTP). Lack of awareness of the level of disability by these symptoms by health professionals may create difficulties when providing clearance for RTP and appropriate interventions.
Methods: An online survey gathered data on symptoms, mental health, fear, pain catastrophizing, and disability in adult athletes. A small convenience sample of concussed athletes participated in an online interview about specific impairments, the emotional toll of being concussed, and their impact on their life in and out of sport.
Results: This concussion group had clinically relevant scores in Rivermead Head Injury Follow-up Questionnaire (RHFUQ), mental health, kinesiophobia, and cogniphobia. Depression, age, RPQ13, and kinesiophobia were predictors to disability. When controlling for their current mental health status, strong correlation was found between RHFUQ and mental health and between kinesiophobia, pain catastrophizing and cogniphobia. Participant interviews supported the findings with statements around emotional expression, sociological impacts, cognitive deficits, and physical dysfunction. Emotional disturbances and social interactions were the most discussed amongst participants and related to work, school, and relationships.
Conclusions: Adult athletes with prolonged symptoms of SRC live with many physical, emotional, and sociological impairments. To reduce disability, their depression, concussion symptoms, and fear should be addressed swiftly. Decisions regarding RTP need to consider RPQ, fear, mental health, and disability for each athlete.
501 Mind and body: impact of an eight-week community taekwondo training program in individuals with chronic acquired brain injury
Carolyn Tassinia, Emily Bubelb, Melissa Yangb, Jamie Younga, Caitlin M. Ogram Buckleya
aBancroft NeuroRehab, Cherry Hill, USA, bSaint Joseph’s University, Philadelphia, USA
ABSTRACT
Background: Brain injury often results in deficits in balance and attention which may persist several years post injury and can impact an individual’s safety and quality of life. While certain “softer” styles of martial arts such as qigong have been shown to make improvements in balance, “harder” styles, such as taekwondo have not been studied in this population.
Objective: To evaluate the impact and feasibility of an eight-week community taekwondo program on balance, attention, and occupational abilities in individuals with chronic brain injury.
Participants: Eight participants were randomly selected from a neurorehabilitation center in the Northeastern USA. Participants had a mean age of 38.9 (SD = 12.9) and were all male. All participants were independent or required supervision when ambulating using a unilateral assistive device or no device.
Methods: Study design was an eight-week quasi-experimental pretest/posttest pilot study. The intervention phase included an eight-week course of training in taekwondo. Classes consisted of dynamic warm-ups and stretching, hand and kicking techniques, learning a taekwondo form, and self-defense. Outcome measures included the MiniBEST to assess balance and fall risk, Conners Continuous Performance Test-3rd Edition (CPT3) as a measure of sustained attention, and the Canadian Occupational Performance Measure (COPM) to assess self-perceived occupational performance. As participants completed the miniBEST at three timepoints (pre/post and 30-day retention), a repeated-measures ANOVA was conducted for this measure, whereas a paired samples t-test analyzed CPT and COPM performance at pre/post timepoints.
Results: Full data was available for six participants, two participants withdrew mid-study. MiniBEST Total Score [F (1,2) = 11.32, p = 0.005] significantly improved across timepoints. Post hoc pairwise comparisons revealed significant improvements between baseline performance and immediately following the intervention (p = 0.023) as well as at 30-day retention (p = 0.022). CPT HRT SD [t(5) = 3.29, p = 0.02] and CPT ISI Change [t(4) = 3.58, p = 0.023] significantly improved following intervention. No significant change was observed in reported occupational performance [COPM; t(6) = −1.04, p = 0.337]. Five controlled falls occurred over the duration of the study with no resulting injuries.
Discussion: This study suggests that taekwondo is safe and feasible as a community intervention for individuals with chronic brain injury. Meaningful gains were achieved in domains of attention and balance while providing a fun and engaging environment. Further studies should explore longitudinal gains utilizing a larger more diverse sample, and include additional cognitive, emotional/behavioral, and motor metrics. Because additional gains were reported outside of training in domains such as memory and initiation, future studies should also explore methods with which to capture these qualitative benefits. The impact of these observed gains and their influence on community engagement and relationships should also be considered.
502 Exploring episodic memory in the adult population with prolonged symptoms after a sport-related concussion
Vicki Wonga, Matthew Holahana
aCarleton University, Ottawa, Canada
ABSTRACT
Introduction: Adults who participate in sports in their community are at risk of a sport-related concussion (SRC). A common complaint afterward pertains to cognitive function, especially memory function. Memory should be assessed as part of the return to play (RTP) plan alongside the typical concussion symptom presentation. It was expected that those with a higher severity of symptoms would display decreased episodic memory on a novel assessment tool.
Methods: After completing a small pilot study to assess the feasibility of a novel assessment tool, the Means End Problem Solving Procedure (MEPS), a larger study was performed as an online survey. Data on current concussion symptoms were collected from adults who had an SRC over 1 month prior and healthy controls. Both groups completed the MEPS where participants are presented with the beginnings and endings of four interpersonal problem situations, and they describe the middle portion. The MEPS requires participants to use memories of personal experiences to complete the story.
Results: A MANCOVA test between groups for 4 MEPS stories and the Rivermead Post-Concussion Symptoms Questionnaire analyzed as the RPQ3 and RPQ13 with a covariate for their current psychological status was found to be significant in both the pilot and the full studies. In the pilot study, univariate analysis found significance differences for MEPS 10 and RPQ13 between the groups. In the full study, only RPQ3 and RPQ13 were significantly different, indicating that it was the symptom severity and not the episodic memory creating the differences between groups.
Conclusions: Episodic memory deficits may play a role in the memory complaints in those with prolonged SRC symptoms, however, the current study was inclusive. The MEPS is a promising assessment tool for episodic memory and should be reassessed with a larger sample size.
503 Disability, kinesiophobia, and mental health in adult athletes with prolonged symptoms of sport-related concussion
Vicki Wonga, Matthew Holahana
aCarleton University, Ottawa, Canada
ABSTRACT
Introduction: Adult athletes are an understudied population with sport-related concussion (SRC). While most recover within two weeks, some athletes live with prolonged concussion-associated symptoms. The findings of this study will expand on the understanding of the concussion symptoms that need to be assessed in adult athletes prior to their return to play.
Methods: An online survey gathered data on symptoms, mental health, sleep changes, fear, and disability in adults who had an SRC over 1 month prior. Mental health and basic symptoms were compared to controls.
Results: Using a MANOVA, the concussion group showed significant, clinically relevant levels of concussion symptoms and mental health distress compared to controls. They also had high fear avoidance behavior and disability. Significant and large positive correlations were seen between Rivermead Post-Concussion Symptoms Questionnaire (RPQ13) and anxiety and stress. Disability on the Rivermead Head Injury Follow-Up Questionnaire (RHFUQ) was associated with RPQ13, Tampa Scale of Kinesiophobia (TSK), and Stress.
Conclusions: Adult athletes with prolonged symptoms of SRC live with many physical, emotional, and sociological impairments. Decisions regarding RTP need to consider RPQ, fear, mental health, and disability for each athlete.
504 Cardiovascular and neurophysiological responses during overground exoskeleton gait training after severe acquired brain injury: a case series
Jaime Gillespiea, Elizabeth Teelc, Dannae Arnolda, Molly Trammella, Christa Ochoab, Hui-Ting Shihb, Rosemary Dubiela,d, Simon Drivera,b, Chad Swanka,b
aBaylor Scott & White Institute for Rehabilitation, Dallas, USA, bBaylor Scott & White Research Institute, Dallas, USA, cConcordia University, Loyola Campus, Montreal, Canada, dBaylor Scott & White University Medical Center, Dallas, USA
ABSTRACT
Purpose: Clinical practice recommendations advise development of interventions to increase arousal and upright tolerance for patients with severe acquired brain injury (ABI). Overground exoskeleton gait training (OEGT) has been found to be feasible, safe, and allow physical therapists to mobilize low functioning patients. The purpose of this case series is to describe the impact of OEGT use on cardiovascular and neurophysiological responses in people with severe ABI during inpatient rehabilitation.
Methods: Two patients completed a total of 3 OEGT sessions during inpatient rehabilitation. OEGT session data (up time, walk time, step count, and device limb swing assistance) were recorded. Cardiovascular response was monitored continuously during OEGT with a heart rate monitor (RS300X, Polar®) and categorized into intensity zones based on heart rate reserve (HRR): Very Light (< 30%), Light (30–39%), Moderate (40–59%), Vigorous (> 60%). Neurophysiological responses were monitored by a 24-channel mobile electroencephalograph (EEG) system with maximum 1000 Hz sampling, 24-bit resolution, 500 ohm input impedance, 1 µV input referred noise and CMRR > 110 dB. Markers were placed in the EEG recording to indicate patient positions of sitting, standing, and walking during OEGT.
Results: Participant A (Sessions 1 and 2) was a 26-year-old male admitted with ongoing disorder of consciousness 81 days after traumatic brain injury. Initial Glasgow Coma Scale (GCS) was 6 T and Rancho Los Amigos Scale was level III at inpatient rehabilitation admission. Participant B (Session 3) was a 55-year-old male admitted to inpatient rehabilitation 169 days after anoxic brain injury due to cardiac arrest with an initial GCS of 3T. OEGT session data and cardiovascular response suggest good tolerance. Sessions 1, 2 and 3 data included OEGT data [up time = 17.08 minutes, 18.02, 21.88; walk time = 13.97 minutes, 14.65, 19.03; step count = 300, 320, 298; swing assist = 60%, 52.5%, 65%] and HRR intensity [Very Light 88%, 67%, 32%; Light 12%, 33%, 12%; Moderate 0%, 0%, 56%; Vigorous 0%]. Visual observations of increased arousal and alertness were most notable with positional changes (e.g., sit to stand, initiating walking) during OEGT. EEG data of OEGT will be reported and is pending analysis.
Conclusion: Patients with severe ABI tolerated OEGT during inpatient rehabilitation with a modest cardiovascular response. Visually observed changes in arousal were observed during upright positioning. Future efforts may consider examining the relationship between neurophysiological responses and visual observations of arousal during OEGT after severe ABI.
505 Identifying early factors related to behavioral problems in adult brain injury patients: a worthwhile procedure
Jan Wiersmaa, Sanne de Leeuwa
aInteraktcontour, Arnhem, Nederland
ABSTRACT
Brain injury is an important cause of disability. The long-term neuropsychiatric sequelae are severe with a heavy burden for everybody involved. Treatment is difficult. The Dutch guideline on the neuropsychiatric sequelae after brain injury (2017) shows that the evidence for the treatment of behavioral problems is weak leaving much room for uncertainty in the treatment. Early identification could lead to early management of treatment with potentially better results. This could improve the quality of life of both patients and everyone involved.
We compared (retrospectively) two groups to investigate whether it would be possible to distinguish patients with complex behavior (CB) from a non-complex group (N-CB) based on 68 factors divided in 12 clusters. For example: premorbid psychiatric history, addiction. File information upon referral was used. No information was obtained from the follow up. We asked the practitioners to deliver patients with or without behavioral problems. The CB group included 27 patients (18 males and 9 females; mean age 55.4 years) and the N-CB group included 20 patients (11 males and 9 females; mean age 50.8 years). Each of the 68 factors where weighed by clinical judgment as to whether it was no early signal of behavioral problems, a possible or a clear early signal. A clear signal is the so-called ‘red flag’: that will very likely cause behavioral problems.
The CB-group consisted of 1836 (27 x 68) and the N-CB-group of 1360 (20 x 68) weighings. It turned out that in the N-CB group 0% (of the 1360 weighings) was valued as a ‘clear signal.’ In the CB-group this was 15.8%. Adding the weighings ‘possible’ and ‘clear’ together this was 38.2% of the CB-group and only 9% in the N-CB group. When looking at the lowest and highest percentages of this combination in the two groups, it turned out that the spread in the CB-group was between 22.1% and 61.8%, while for the N-CB group it was between 0 and 32.4%. In other words, a systematic assessment of the 68 factors by means of a clinical weighing of file information at referral shows an almost complete separation between the two groups. This is relevant information when drawing up a treatment plan and to prepare a team for the development of behavioral problems.
Conclusion:
1) Systematic factor weighing provides clarity whether a patient belongs to the N-BC group or the CB group. This is important for the management of the treatment.
2) If only 1 factor out of 68 is judged as a clear signal for problem behavior, there is a good chance that the patient belongs to the CB group.
Further research should clarify which factors are (mainly) decisive and which are not.
506 Older adults with mild traumatic brain injury: demographics, fracture and mechanism of injury
Crystal Ramseya, Karen McCullochb, Vicki Mercerb, Lindsey Byomb
aElon University, Elon, USA, bUniversity of North Carolina Chapel Hill, Chapel Hill, USA
ABSTRACT
Objective: Mild traumatic brain injuries (mTBI) are common among older adults, however most research has focused on younger populations. Older adults are most likely to sustain mTBI due to a fall with approximately 10% of falls resulting in fracture. There is little information on the relationship between mTBI and fracture in older adults, limiting the evaluation of efficacy of current concussion clinical practice guidelines which were developed for younger populations. The objectives of this study were to investigate, in a clinical sample of older adults with mTBI, the mechanism of injury (MOI) and incidence and type of concomitant fracture.
Methods: This research is part of a larger retrospective study of electronic medical record data of total 3807 older adults with TBI who received healthcare within a large US medical system between 2014 and 2018. Participants were 65–89 years old at the time of injury and were diagnosed with mTBI as defined in the 2020 clinical practice guideline for physical therapy management of mTBI. Demographic variables were characterized using descriptive statistics. Concomitant fracture and fracture type were described. MOIs were identified and the presence of fracture across MOIs was examined using chi square test of homogeneity.
Results: Of the larger TBI sample, 638 (16.8%) participants had mTBI and of those, 394 were female (61.8%). Most participants were white (84.5%) or Black (8.9%) and average age was 71.9 years (Standard Deviation = 7.1 years). Falls were the most common MOI (63.2%), followed by motor vehicle crashes (17.2%). Seventy-two participants with mTBI (11.3%) had a fracture concomitant with mTBI. 54.2% of fractures were axial, 18.1% upper extremity (UE), 9.7% lower extremity (LE), and 18.1% of participants with fracture sustained multiple concomitant fractures. Concomitant fracture incidence differed by MOI (χ2 = 10.26, p = 0.02) with most due to falls and motor vehicle crashes.
Conclusions: Demographic characteristics of this sample of older adults with mTBI were like those previously reported in geriatric TBI studies. It is noted however, that while most TBIs are mild, only 16.8% of our TBI sample had mild injuries. Fall was the primary MOI followed by motor vehicle crashes. Axial skeleton fractures were most common in our sample, differing from a previous study demonstrating an association of UE fracture with mTBI. The low percentage of fractures in the sample was also unexpected. Only 11.3% of our total sample of older adults with mTBI had co-occurring fracture. We speculate that mTBI may be underdiagnosed in older adults overall, and in those who have sustained trauma. The high percentage of white patients diagnosed with mTBI also raises questions about whether the possibility of mTBI is considered consistently across all racial groups.
507 How do assessments of unilateral spatial neglect address far space? A scoping review
Frédérique Ponceta,b,c, Lissa Marque Wanderleyb,c, Eric Soritad,e, Saj Arnaudb,f, Cyril Duclosb,g,h, Noemie Duclosd,e
aCIUSSS Center Ouest de l’ile de Montréal, Montréal, Québec, Canada, bCentre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montréal, Canada, cSchool of Optometry, University of Montreal, Montréal, Québec, Canada, dInstitut Universitaire des Sciences de la Réadaptation, College of Health Sciences, University of Bordeaux, Bordeaux, France, eBordeaux Population Health Research Center, INSERM U1219, University of Bordeaux, Bordeaux, France, fFaculté des arts et des sciences – Département de psychologie, University of Montreal, Montréal, Québec, Canada, gSchool of Rehabilitation, University of Montreal, Montréal, Québec, Canada, hInstitut universitaire sur la réadaptation en déficience physique de Montréal, CIUSSS Center-Sud-de-l’Île-de-Montréal, Montréal, Québec, Canada
ABSTRACT
Purpose: Unilateral Spatial Neglect (USN) is a neurological disorder characterized by reduced attention on the space toward the contralesional side, is a common deficit after stroke (30%). A USN patient can have difficulties in activities of daily living in near and far spaces. Far space can be defined as a space where the target is beyond reaching distance (e.g., signposts, a moving vehicle onto the road). The paper-and-pencil tests are the most popular tests to assess USN. However, these tests cannot evaluate the impact of USN in deep space or daily life activities. A scoping review was performed to identify tools that assess USN in far space and to analyze the suitability of these tools to detect daily life impairments.
Methods: A scoping review was conducted on the literature published until 2019. It followed the six-stage framework recommended by Levac et al. (2010) for a quality scoping review. Using a systematic procedure, literature was selected from 4 databases (i.e., MEDLINE, Embase, CINAHL, and PsycINFO). Results were charted and tools were analyzed concerning their goals, psychometric properties, applicability, and analyzed according to the International Classification of Functioning (ICF).
Results: After removing duplicates, 1749 studies were screened. Twenty-four articles were included in this scoping review. Eleven tools were extracted: five take place in the natural environment and six in a virtual environment. Regarding the complexity of the task, most of the tools used multiple tasks. Catherine Bergego scale and Mobility Assessment Course (MAC), conducted in the natural environment, presented the best psychometric properties. The ecological validation of virtual tools is rarely studied. Concerning the applicability, the natural environment tools are available free of cost and no training is required to use them unlike virtual tools. According to ICF, the activities assessed the activities assessed by the tools were categorized into eight domains: Carrying out daily routine; Conversation and use of communication devices and techniques; Carrying, moving and handling objects; Walking and moving; Dressing; Eating; General interpersonal interactions; Recreation and leisure (d 920). Among the domains, only two (Walking and moving and carrying out daily routine) address far space.
Conclusions: Both natural and virtual environments seem to be suitable for assessing far neglect in USN persons. VR tools still need more research regarding their psychometric properties to be used in clinical settings. To properly consider the impact of USN in deep space, studies should be conducted to be able to offer evaluations that would consider other areas of activity (e.g., leisure, sport).
508 Short, medium and long term pituitary follow-up in children and adolescents after traumatic brain injury.
Eliane Huarda,b, Luis Castrob, Bernardo Martinsa
aSARAH Network of Rehabilitation Hospitals, Brasilia, Brazil, bUniversidade de Brasília (UNB), Brasilia, Brazil
ABSTRACT
Introduction: Pituitary Radiological study is important to evaluate hypothalamus/pituitary axis problems.There are studies that describe correlation between pituitary radiological abnormalities and hipopituitarism at general population, but few studies describe neuroradiological abnormalities after traumatic brain injury in pediatric population, and, when they do, it´s only at isolated case reports.
Objectives: Studying routine traumatic brain injured patients magnetic resonance images (MRI), evaluating pituitary morphology and volume in a pediatric population.
Methods: It is a longitudinal retrospective cases serie study, including 78 children and adolescents that are being followed at our Rehabilitation Center between 2009 and 2021. MRI Technique 1,5 or 3,0 millimeter contiguous sagittal and coronal plain through the sella were obtained using superconducting MRI units. A Developmental and Rehabilitation Pediatrician has been trained by a Neurorradiologist and performed at the morphological pituitary analysis. Pituitary volume was measured using the formula: coronal width X coronal height X sagital width X 0,5. The results were compared to preexisting parameters for age and sex. We used the Program AquariusNet Viwer (AqNet) Versão V4.4.13.P4 (522).
Results: We studied 47 males and 31 females. Some patients had more than one sequential study, so, totally, we evaluated 151 images. Age at MRI test went from 11 months old to 18 years old. Age at traumatic brain injury went from 0,2 to 16,9 years old. Time after traumativ brain injury went from 0,2 to 14 follow up years. We found pituitary abnormalitie at 29 from 123 MRI exams (23%) or in 25 from 74 patients (32%).All patients with radiological pituitary abnormalities had previous severe traumatic brain injury, according to Glasgow Coma Scale. From those patients, 72% were females. We found two “empty sella syndrome” situations, one caused by “pituitary stalk transection syndrome”; one pituitary cist (Rathke); and 22 cases with reduced pituitary volume, when compared to normal controls.
Conclusions: Structural pituitary abnormalities have been found in 32% of our patients. It is important to closely follow- up these patients in the long-term so that their natural history of progressive radiological and hormonal deterioration can be ascertained.
509 Pediatric concussion alters cardiac mechanical function: case study
J. Patrick Nearya, Jyotpal Singha
aUniversity of Regina, Regina, Canada
ABSTRACT
Background: Research has shown that cardiac function is affected in adults that sustain a mild traumatic brain injury (mTBI), or concussion. Concussion can result in altered neuro-autonomic function leading to changes in cerebrovascular and cardiac mechanics. However, impairments in cardiac function following concussion are not well understood in pediatric populations. Knowing this information could be used to guide player return-to-play and return-to-learn safely.
Methods: We used a noninvasive cardiac sensor (LLA Recordis™) to record the cardiac cycle timing events and contractile function of the heart. The cardiac sensor was snapped into a single adhesive ECG gel-electrode and placed 1 cm above the xiphoid process on the sternum of the chest over the skin. The male participant (age 13 years) was in a restful supine position for approximately 1-minute prior to turning on the cardiac sensor. Cardiac data was collected for 1-minute thereafter. Data was collected at days 1, 2, 3, 4, 7, 14, 21, 28, and 120 post-concussion. All data was collected at the same time each day under similar conditions.
Results: On day 1, Twist Force (a surrogate measure of contractility in milligravity; mG) was reduced (23 mG) in comparison to day 120 (“baseline”; 36 mG), but was highest on day 7 (53 mG). Isovolumic contraction time was elevated to 43.4, 37.7, and 37.8 milliseconds (ms) at days 1, 2 and 7, respectively, in comparison to day 120 (31.3 ms). Systole was depressed at days 4 and 7 to 291 and 258 ms compared to 309 ms on day 120. Rapid ejection period and mitral valve open to early diastolic filling time showed varying results throughout the first 28 days, and notably, rapid ejection period was depressed at days 2, 3, 14, 21 and 28. Diastole was greatly depressed at day 28 (284 ms) in comparison to day 120 (518 ms). The myocardial performance index (i.e., Tei index) was abnormally high on day 1 (0.43), 4 (0.44), 7 (0.49), and 14 (0.43) in comparison to day 120 (0.38). The sum of the Sport Concussion Assessment Tool (SCAT) symptom scale decreased continuously on a day-to-day basis reflecting improvements in symptoms from day 1 (46) to day 120 (0).
Conclusion: This is the first study to document daily changes in the cardiac cycle timing events in a pediatric concussion case study. Both systolic and diastolic changes were noted that varied daily, and cardiac impairments were sustained with elevated SCAT symptoms. These results confirm that concussion altered the mechanical function of the heart in this pediatric participant. Future research is warranted to confirm these individual results in a larger population of pediatric patients.
510 The gaelic athletic association/UPMC Ireland concussion baseline testing pilot: overview and barriers to participation
Hannah Bitzera, Robin Cairdc, Janita Basitc, Phillip O’Halloranb,c,d, John Windleb, Michael Collinsa, Anthony Kontosa
aUniversity of Pittsburgh, Department of Orthopedic Surgery, Pittsburgh, USA, bUPMC Ireland, Lisduggan, Ireland, cRoyal College of Surgeons in Ireland, Dublin 2, Ireland, dDepartment of Neurosurgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
ABSTRACT
Background: Sport-related concussions affect athletes across many GAA sports. These injuries may result in cognitive(WHO, 2019; ACRM, 1993), physical (ACRM, 1993) and emotional impairment(ACRM, 1993). Determining when an athlete is impaired and recovered following a concussion is essential for protecting player health and safety. Trained clinicians can use baseline or pre-injury data to evaluate impairment, track recovery, and determine full return-to-play status following concussion. Currently, in Ireland, there are no baseline testing programs that have been implemented in GAA sports.
Purpose: To develop, pilot, and report preliminary findings related to the challenges and barriers of a computerized neurocognitive baseline testing program involving GAA athletes.
Methods: Representatives for 24 GAA teams were contacted to gauge interest in their team participating in the pilot program. Teams were offered in-person or remote testing sessions and all data were collected prior to engagement in regular season games. Post-injury follow-up testing and clinical care were offered at no-cost to all participating teams. The pilot program utilized a 20–30 minute, computer-based neurocognitive assessment called the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) to establish overall pre-injury cognitive status in several domains including verbal and visual memory, reaction time, and impulse control. The ImPACT includes a demographic section and incorporates a 22-item symptom report where individuals report their current symptoms on a 0 (none) to 6 (severe) scale called the Post-Concussion Symptom Score (PCSS). Symptom domains include physical (e.g., headache), cognitive (e.g., difficulty remembering) and emotion (e.g., increased irritability).
Results: 18 out of 24 teams (14 men’s, 4 ladies) participated in the pilot program representing approximately 500 individual baseline tests. Nearly 75% of the ImPACT tests were completed in-person and 79% of participants were male. The implementation of the pilot program revealed barriers to guide the construct of a nationwide rollout of the program to all GAA athletes. Barriers for full participation included: access to players, perceived time available to dedicate to baseline testing, and support or timely response of management.
Conclusion: The pilot program and its data helped to support and inform a systematic process for a national rollout of the program in collaboration with the GAA and the GPA. The high level of engagement in baseline testing suggests that the pilot baseline program could be implemented at a national level across all codes but barriers to full participation must be addressed. Organizers of a national program should consider utilizing key stakeholders at organizations that interact directly with female GAA athletes to increase their participation for a more representative sample of GAA athletes. Baseline testing can provide pre- and post-injury data to establish normative data, inform better clinical care, and expand our understanding of concussion and its effects on GAA and other athletes in Ireland.
511 Characterization of the activities-specific balance confidence scale (ABC scale) and its relationship to gait and balance measures in community-dwelling adults with concussion: findings from the toronto concussion study
George Mochizukia,b, Elizabeth Innessb,c,e, Mark Bayleyb,c, Tharshini Chandrab, Paul Comperb,c,d, Cynthia Danellsb,e, Norman Danga, Evan Fosterb, Hajr Hameeda
aSchool of Kinesiology and Health Science, York University, Toronto, Canada, bToronto Rehabilitation Institute – University Health Network, Toronto, Canada, cRehabilitation Sciences Institute – University of Toronto, Toronto, Canada, dFaculty of Kinesiology and Physical Education – University of Toronto, Toronto, Canada, eDepartment of Physical Therapy – University of Toronto, Toronto, Canada
ABSTRACT
Objective: Community-dwelling adults with concussion often endorse symptoms related to dizziness and balance problems, generate balance errors during assessments and display alterations in balance outcomes as measured on a forceplate. What remains unclear is whether these indicators of alterations in balance function after injury translate to confidence in maintaining balance during functional activities. The aim of this study was to characterize the level of balance confidence in adults from the general population within 7 days of sustaining a concussion using the Activities-specific Balance Confidence Scale (ABC Scale) and to probe the relationship between measures of balance confidence with measures of balance and gait from across different domains.
Methods: This was a retrospective analysis of data that were collected on participants referred to Hull-Ellis Concussion and Research Clinic at the Toronto Rehabilitation Institute from 6 partnering emergency departments in which concussion was diagnosed. To be included in the analysis, non-compensation seeking adults between the ages of 18 and 85 with concussion had to have been assessed within 7 days of injury, have a Glasgow Coma Score of 13–15 in the emergency department, and have no positive findings on brain imaging. Relationships between ABC and balance (SCAT3 individual symptom score and sub-domain cluster scores, modified Balance Error Scoring System (mBESS), and forceplate) and gait measures (Double Support Time (% of gait cycle) – indicating cautious gait behavior) were assessed using Spearman’s correlations (ρ).
Results: The mean ABC Scale score across all participants was 83.4 ± 17.8%. Of the 253 individuals included in the analysis, 73.8% had an ABC Scale score >80%. The relationship between ABC Scale scores and clinical (mBESS) or objective (forceplate-derived) measures of balance were not statistically significant. Associations between balance confidence and cautious gait behavior (DST) were low (ρ = −0.160 to −0.212), but these were not significant after correcting for multiple comparisons. These tasks included walking at a self-selected pace, walking while performing a Backwards 7ʹs task, and walking while counting upwards by 1. In contrast, ABC had low-to-strong, statistically significant correlations across all SCAT3 symptoms (ρ = −0.248 (neck pain) to −0.621 (balance), p < 0.001). The strength of relationships was maintained between ABC and domain score (ρ = −0.366 (headache) to −0.602 (vestibulocular), p < 0.001).
Conclusion: The ABC is a tool used to assess confidence during functional balance activities. As a subjective tool, the ABC was most strongly associated with subjective symptom endorsement as well as clusters of symptoms across domains. The strongest associations were observed in symptoms or clusters of symptoms associated with balance. Future work is needed to establish the psychometric properties of the ABC Scale score in adults from the general population with concussion.
512 Clinical evolution and outcome predictors in patients with post-anoxic prolonged disorders of consciousness: a systematic review and meta-analysis
Alfonso Magliacanoa, Francesco De Bellisb, Francesco Panicoc, Laura Saglianoc, Luigi Trojanoc, Claudio Sandronid,e, Anna Estraneoa,e
aIRCCS Fondazione Don Gnocchi ONLUS, Florence, Italy, bPolo Specialistico Riabilitativo, Fondazione Don Carlo Gnocchi ONLUS, Sant’Angelo dei Lombardi (AV), Italy, cDepartment of Psychology, University of Campania “Luigi Vanvitelli,” Caserta, Italy, dDepartment of Intensive Care, Emergency Medicine and Anesthesiology, Fondazione Policlinico Universitario “Agostino Gemelli,” IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
ABSTRACT
Background: The clinical outcome of patients with prolonged Disorder of Consciousness (pDoC; i.e., Vegetative State/Unresponsive Wakefulness Syndrome, VS/UWS, or Minimally Conscious State, MCS) due to severe anoxic brain injury is usually worse than in pDoC due to vascular or traumatic etiologies1. Moreover, post-anoxic patients with pDoC show higher clinical complexity, functional disability, and need of medical devices2. These factors contributed to the paucity of long-term follow-up studies in anoxic pDoC patients and greater uncertainty about their clinical evolution and prognosis. We present a systematic review and meta-analysis of prognostic studies on post-anoxic pDoC aimed at evaluating long-term outcome, and at identifying its possible demographic and clinical predictors.
Methods: A systematic literature search provided a total of 25 eligible studies. Meta-analyses of proportions were performed to evaluate the rates of mortality, any clinical improvement, and recovery of full consciousness at least 6 months after the brain injury. Additionally, a cross-sectional approach was used to identify significant differences in demographic and baseline clinical characteristics between deceased vs. survivors, improved vs. not-improved patients, and recovery vs. not-recovery of full consciousness.
Results: We found a pooled mortality rate of 30%, a rate of any clinical improvement of 23%, and a rate of full consciousness recovery of 14%. Younger age, diagnosis of MCS vs. VS/UWS, and higher level of responsiveness/consciousness, as assessed by the Coma Recovery Scale-Revised (CRS-R) total score at study entry, were associated with a lower likelihood of mortality. Moreover, these same variables, together with shorter time from brain injury, were also associated with clinical improvement and recovery of full consciousness.
Conclusions: To the best of our knowledge, this is the first meta-analysis evaluating the rates of mortality, clinical improvement and recovery of full consciousness at least 6 months after anoxic injury. Moreover, we identified the variables easy to collect at bedside with significant prognostic value in patients with anoxic pDoC. This study might help clinicians to predict the long-term outcome of such complex patients and to plan tailored care pathways, in order to optimize the use of healthcare resources and provide patients’ relatives with more accurate information.
References
1. Estraneo et al. 2010. Late recovery after traumatic, anoxic, or hemorrhagic long-lasting vegetative state. Neurology, 75(3):239–245.
2. Estraneo et al. 2019. Demographical and clinical indices for long-term evolution of patients in vegetative or in minimally conscious state. Brain Inj, 33(13–14):1633–1639.
513 Prediction of functional decline 2 to 5 years after moderate-severe traumatic brain injury: a machine learning approach
Shanti Pintoa, Yulun Liua, Kan Dinga, Rong Zhanga,b, Kathleen Bella
aUniversity Of Texas Southwestern Medical Center, Dallas, USA, bInstitute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, Dallas, USA
ABSTRACT
While many individuals with traumatic brain injury (TBI) remain stable years after injury, a subset of individuals will have improvement or decline in function. New techniques of machine learning may improve our ability to predict outcome and identify populations needing focused intervention. The objective of this study was to pilot the use of a machine-learning approach to identify predictors of functional decline or improvement two to five years post-TBI. The sample included 198 individuals in the local TBI Model Systems database with Disability Rating Scale functioning (DRSF) subscores at two- and five-years after moderate-severe TBI. Individuals were identified as “declining” (DRSF increased >1 point), “improving” (DRSF decreased >1 point), and “stable” (DRSF change <1 point) between the time points. The study sample was randomly divided into the training and test sets with a ratio of 7:3. Given the relatively small sample size, the Random Forest (RF) algorithm was employed to predict the changes in DRS scores; multiple decision trees were constructed to prevent over-fitting of the training set. The Shapley Additive exPlanations (SHAP) was utilized to provide accurate attribution values for each important feature identified with the RF models. The performance of the RF model with the test set was assessed by the area under the receiver operating characteristic curve (AUC). Twenty-four demographic and injury-related features (Glasgow Coma Scale [GCS], post-traumatic amnesia (PTA) duration, CT head imaging findings, et al) were included in the model. Only 111 individuals in the sample had all covariates, of which 13 (11.7%) had declining function, 15 (13.5%) had improving function, and 83 (74.8%) were stable. The top 10 most important features in the RF model included Functional Independence Measure motor (FIMMOTD) at inpatient rehabilitation (IPR) discharge, IPR length of stay (LOS), education, age, PTA duration, FIM cognitive at IPR discharge, employment, time to follow commands, CT head imaging findings, and acute hospital LOS. The SHAP identified the features that most influenced the RF model. Individuals with higher GCS and FIMMOTD were more likely to have declining function, and those with older age, greater education, longer duration of PTA, and lower FIMMOTD were more likely to have improving function between two- and five-years post-injury The AUC of the RF model based on the test set was 0.694 (95% CI: 0.519–0.837). These findings suggest that functional improvement may occur 2–5 years post-injury in those with greater severity of TBI. Unexpectedly, those with higher GCS and lower motor impairments at rehabilitation discharge may be at risk of functional decline. This may reflect emerging data on declining levels of physical activity for those with TBI over time, even for those with moderate injuries. More research is needed to validate these findings in a large independent dataset.
514 Challenges and successes in the application of the strength-based approach for people living with traumatic brain injuries
Pascale Simarda,b, Samuel Turcottec,f, Catherine Valléea,d,e, Marie-Eve Lamontagnea,b
aUniversité Laval, Québec, Canada, bCentre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, Canada, cCentre de recherche de l’Institut universitaire en gériatrie de Montréal (CRIUGM), Montréal, Canada, dVitam-Université Laval, Québec, Canada, eCentre de recherche CERVO-Université Laval, Québec, Canada, fUniversité de Montréal, Montréal, Canada
ABSTRACT
Introduction: Community organizations play an important role in supporting the everyday life of people living with the aftermath of a traumatic brain injury [TBI]. These organizations must implement evidence-based practices to provide quality services to their beneficiaries. The strengths-based approach [SBA] is a model of case management that was originally developed for people living with severe mental illness. The SBA builds on a person’s strengths and environmental resources to support community integration and a positive identity. A Canadian community-based organization serving people living with a moderate or severe TBI and their relatives implements key parameters of this approach within their services. This is the first implementation study of the SBA for adults living with the aftermath of a TBI.
Objective: To document the implementation of SBA key intervention parameters.
Methods: Using a descriptive qualitative approach, individual semi-structured interviews were conducted before (n = 10) and after (n = 8) the implementation of the approach with community workers from the organization. The interview guides were developed based on scientific literature describing SBA key intervention parameters and were pretested with a community worker. The interviews were audio-recorded. Transcribed verbatims were analyzed in inductive and deductive way using Nvivo software.
Results: Group supervision technique as well as the evaluation and mobilization of personal strengths are SBA key intervention parameters that were successfully implemented within the services, according to participants. The evaluation/mobilization of environmental strengths and the provision of individual supervision of community workers are reported to be less successfully implanted within the community organization. Beyond the implementation of the key parameters, the participants reported positive changes inherent to the implementation process, such as 1) an increased cohesiveness within service teams and across the services; 2) a better structuration of interventions, and more collaboration and involvement of the service users.
Conclusion: This study suggests that it is possible to implement an adaptation of the SBA for people living with the sequelae of a TBI. Although not all of the key parameters are being successfully implemented, the implementation process is described as leading to positive changes within the community organization.
515 Characterization of the antibodies utilized in the leading neurofilament NF-L biomarker assays gives interesting functional and scientific insights. these insights also lead to the development of a panel of novel immunocytochemical markers of neurodegeneration
Gerry Shawa,b,c, Irina Madorskya, Ying Lia, YongSheng Wanga, Marda Jorgensena, Sabhya Ranac,d,e, David Fullerc,d,e
aEncor Biotechnology Inc., Gainesville, USA, bDepartment of Neuroscience, University of Florida, Gainesville, USA, cMcKnight Brain Institute, Gainesville, USA, dDepartment of Physical Therapy, Gainesville, USA, eBreathing Research and Therapeutics Center, Gainesville, USA
ABSTRACT
Recent work shows that certain immunological assays for the neurofilament light chain NF-L detect informative signals in the CSF and blood of human and animals affected by a variety of CNS injury and disease states. Much of this work has been performed using two mouse monoclonal antibodies to NF-L, UD1 and UD2, also known as 2.1 and 47.3 respectively. These are the essential components of the Uman Diagnostics NF-Light™ ELISA kit, the Quanterix Simoa™ bead based NF-L assay and others. We show here that the antibodies bind to neighboring epitopes in a short, conserved and unusual peptide in the NF-L “rod” Coil 2 region. We also describe a surprising and useful feature of Uman and similar reagents. While other well characterized NF-L antibodies show robust staining of countless cells and processes in CNS sections from healthy rats, both Uman antibodies reveal only a minor subset of presumably spontaneously degenerating or degenerated neurons and their processes. However, following experimental mid-cervical injuries to rat spinal cord both Uman antibodies recognize numerous profiles in tissue sections. The Uman positive material was associated with fiber tracts expected to be damaged by the injury administered and the profiles had the swollen, beaded, discontinuous and sinusoidal morphology expected for degenerating and degenerated processes. We also found that several antibodies to the C terminal “tail” region of NF-L stain undamaged axonal profiles but fail to recognize the Uman positive material. The unmasking of the Uman epitopes and the loss of the NF-L tail epitopes can be mimicked by treating sections from healthy animals with proteases suggesting that the immunological changes we have discovered are due to neurodegeneration induced proteolysis. We have also generated a novel panel of monoclonal and polyclonal antibody reagents directed against the region of NF-L including the Uman epitopes which have staining properties identical to the Uman reagents. Using these we show that the NF-L region to which the Uman reagents bind contains further hidden epitopes distinct from those recognized by the two Uman reagents. We speculate that the Uman type epitopes are part of a binding region important for higher order neurofilament assembly. The work provides important insights into the properties of the NF-L biomarker, describes novel and useful properties of Uman type and NF-L tail binding antibodies and provides a hypothesis relevant to further understanding of neurofilament assembly. For further details see https://www.biorxiv.org/content/10.1101/2022.08.27.504533v1.
516 Effects of pre-injury migraine on post-traumatic headache and post-concussion symptoms and recovery in the general adult population: findings from the toronto concussion study
Laura Langera,b, Mark Bayleya,c, Paul Compera,d, Alice Kama, David Lawrenced,e, Alan Tama,c, Lesley Ruttana,f, Cristina Saverinog, Tharshini Chandraa, Evan Fostera, Jonathan Gladstonea,h
aUniversity Health Network – Toronto Rehab, Toronto, Canada, bDalla Lana School of Public Health, University of Toronto, Toronto, Canada, cFaculty of Medicine, University of Toronto, Toronto, Canada, dFaculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada, eMt Sinai Hospital, Toronto, Canada, fDepartment of Psychology, University of Toronto, Toronto, Canada, gUniversity Health Network – Toronto Western Hospital, Toronto, Canada, hThe Hospital for Sick Children, Toronto, Canada
ABSTRACT
Background: Pre-concussion migraine may increase the risk for development of acute post-traumatic headache (PTH) and persistent post-concussion symptoms (PPCS). Acute PTH in the general adult population has not been well characterized prospectively nor has the effect of pre-injury migraine.
Methods: A naturalist cohort of adults diagnosed with concussion in emergency departments seen within 7 days of injury. A standardized questionnaire assessed pre-accident migraine history including migraine history. Participants were followed for 16 weeks completing weekly SCAT-3 symptom, headache questionnaires and biweekly physician assessments. Headache recovery was defined as return to pre-injury frequency of headache.
Results: Participants (n = 302) completed the Headache Questionnaire at Week 1. 178 (59%) were female. 278 (92%) reported a headache at Week 1. 116 (38%) had pre-injury history of migraine with 75% female and mean age 33.3 years (12.1 SD). 97 (84%) had at least 1 migraine in the past year. At week 1, there was no difference in reporting PTH amongst those with pre-injury migraine (p = 0.9). However, those with pre-injury migraine reported PTH at a greater rate than those without migraine history from Week 3 (p = 0.019) to Week 16 (p = −0.01). The migraine cohort had significantly higher SCAT-3 symptom number (16.9 SD 4.7, p < 0.001) and symptom severity (52.3 SD 27.0, p < 0.001) scores than those without prior migraine at Week 1 (p < 0.001) and all weeks assessed (p < 0.001). Those with pre-injury migraines >than once monthly (n = 34), had higher SCAT-3 scores (61.8 SD 25.5, p = 0.001) and symptoms (18.1, 4.5 SD, p = 0.027) than those with less frequent pre-accident migraines at all weeks assessed (p < 0.0001). Those with frequent headaches prior to injury (>monthly) also had elevated SCAT-3 scores than those with less frequent or no headaches prior to injury (p < 0.001). By Week 16, 85% of all participants with reported PTH returned to their pre-injury headache frequency though the group with migraines more than once monthly were still reporting higher rates of PTH than their pre-injury frequency (p = 0.01). History of migraine group were also less likely to be deemed recovered from their concussion by a physician at Week 8 OR 2.60 (95% CI 1.39–4.93, p = 0.0035).
Conclusions: Though in the acute phase of concussion, those with a pre-injury history of migraine are as likely as those without to develop PTH, the former has more severe and persistent concussion symptoms throughout the recovery period. PTH resolves in most people within 3 months of injury. However, Individuals with a pre-injury migraine particularly those with > monthly frequency, have higher rates of PTH following the acute phase and higher risk of PPCS.
517 Evaluation of a group-based intervention for youth with persistent post-concussion symptoms and their caregivers: protocol for the move&connect pilot study
Andrea Hicklinga,b, Andrew Lovella, Hiba Al-Hakeema,c, Kylie Mallorya, Brendan Lama, Christine Provvidenzaa, Tess Bardikoffa, Lindsay Brazilla, Brenda Knappa, Jessica Briana,d, Katie Maha,e, William Montelparef, Nick Reeda,b,g, Shari Wadeh,i, Ruth Wilcockj, Keith Yeatesj,k, Shannon Scratcha,d,g
aBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bDepartment of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada, cFaculty of Humanities and Social Sciences, University of Windsor, Windsor, Canada, dDepartment of Pediatrics, University of Toronto, Toronto, Canada, eSchool of Occupational Therapy, Western University, London, Canada, fDepartment of Applied Human Sciences, University of Prince Edward Island, Charlottetown, Canada, gRehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada, hCincinnati Children’s Hospital Medical Center, Cincinnati, USA, iUniversity of Cincinnati, Cincinnati, USA, jOntario Brain Injury Association (OBIA),, Canada, kDepartment of Psychology and Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, lDepartments of Pediatrics and Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
ABSTRACT
Background: Youth with persistent post-concussion symptoms (PPCS) can experience physical, cognitive, and emotional challenges. Youth and their caregivers are inextricably linked; caregivers of youth with PPCS experience parental distress and poorer family functioning. No interventions are currently available that address the needs of both youth experiencing PPCS and their families simultaneously. Move&Connect is a 6-week group-based intervention, with two program arms: (1) Move&Connect-Youth (M&C-Y), an active rehabilitation, behavioral, and psychoeducation group for youth with PPCS; and, (2) Move&Connect-Caregiver (M&C-C) an adjunct caregiver wellbeing group focused on support, advocacy, and skill development. The intervention was co-designed with youth and caregivers and evaluated through rigorous feasibility testing. This abstract provides a protocol overview of the comprehensive pilot study.
Objectives: (1) pilot M&C-Y in three conditions (in-person, virtual, waitlist control), examining changes in PPCS, youth mental health and self-efficacy, and youth-reported family functioning; (2) pilot M&C-C in three conditions (in-person, virtual, waitlist control), examining changes in caregiver mental health, parenting competency, and parent-reported family functioning; (3) explore the dynamic interplay between youth and caregiver outcomes through mixed effects modeling; and (4) understand the unique experiences and participant perspectives related to Move&Connect.
Methods: This pilot study will use a pre-post mixed-method comparison design. Youth (8–18 years) and caregiver dyads (125 youth, 125 caregivers) will be recruited through the persistent concussion clinic at Holland Bloorview Kids Rehabilitation Hospital (Toronto, Canada) and community organizations. Participants will be allocated to in-person, virtual, or waitlist control conditions, and participant preference will be considered in treatment group allocation. Youth will also be allocated to groups by age/grade (elementary, high school) to account for developmental differences. Participants will complete a series of online self-report measures pre-intervention (week 1), post-intervention (week 8) and at 3-month follow-up. Youth measures will focus on PPCS, mental health, occupational performance, self-efficacy, quality of life, illness perceptions, and family functioning. Caregiver measures will focus on mental health, parenting competency, parent-reported family functioning, and parent-proxy of their child’s functioning. A subset of both youth and caregiver participants will be invited to participate in an exit interview upon completion of the Move&Connect intervention.
Implications: Move&Connect has the potential to improve outcomes for youth with PPCS and their families. This pilot study will examine early evidence of the effectiveness of this group-based intervention in both in-person and virtual conditions. It will also provide important information about the dynamic interplay between youth and caregivers, and participant experiences with Move&Connect. Upon completion of this study, Move&Connect will be ready for larger scale efficacy testing and implementation.
518 Cognitive dual-task effects are more common in service members with mtbi and healthy controls
Karen McCullocha, Courtney Harrisona, Crystal Ramseya,b, Rachana Gangwania
aDivision of Physical Therapy and Curriculum for Human Movement Science, Department of Health Sciences, School of Medicine, UNC-Chapel Hill, Chapel Hill, USA, bDepartment of Physical Therapy, Elon University, Elon, USA
ABSTRACT
Background: The Portable Warrior Test of Tactical Agility, developed for use in mTBI rehabilitation to challenge combined cognitive and motor skills for active duty in military service members (SM), includes a motor component (running, rapid transitional movements including combat rolls while carrying a simulated weapon) and an 8-item working memory task. Each task is examined separately and together in dual-task conditions. We have previously shown significantly higher levels of performance by healthy controls in single AND dual-task conditions of BOTH cognitive and motor tasks, compared to individuals who are initiating a course of physical therapy after mTBI. The purpose of this analysis was to examine patterns of dual-task interference based on a framework that considers possible benefits or costs to either task (or both) in the same sample.
Methods: For 59 healthy control (HC) SM and 61 mTBI active-duty SM we computed relative dual-task effects for each task (difference in single task performance and average dual-task performance over 3 trials, divided by the single task performance level for the task). Motor and cognitive interference, facilitation or tradeoffs were plotted and categorized as 1- no interference (<10%) 2- cognitive facilitation 3-motor facilitation 4- mutual facilitation 5-cognitive interference 6- motor interference 7- motor priority tradeoff 8 – cognitive priority tradeoff and 9- mutual interference. Descriptive statistics and polar plots were used to compare the patterns of interference in the groups.
Results: Common responses for HC SMs were cognitive interference (44%), no interference (27%) and cognitive facilitation (19%). mTBI SMs demonstrated cognitive interference (33%) as the most common response, but a reverse order of cognitive facilitation (25%), and no interference (16%). While fewer mTBI participants demonstrated no interference, the general patterns of response were similar and involved cognitive task changes whereas the motor task performance was relatively consistent.
Conclusion: Differences in patterns of dual-task interference in mTBI were not identified compared to HC peers. In both groups some SMs were 100% accurate with the working memory task in the single task condition, but demonstrated a reduction in accuracy over the 3 dual-task trials (cognitive interference, from multiple working memory sequences presented in a short time span). For others strategy development to remember the 8- item grid coordinate developed during dual-task trials (cognitive facilitation). Test protocol changes could reduce cognitive variation by including additional single task cognitive trials if needed and including breaks between dual-task trials. The nature of military culture emphasizes physical prowess, suggesting physical skills may not be as subject to dual-task effects in this population.
519 An unsupervised learning approach analyzing coma recovery scale-revised sub-scores for predicting recovery from prolonged disorders of consciousness
Anna Estraneoa, Piergiuseppe Liuzzia,b, Rita Formisanoc, Antonello Grippoa, Efthymios Angelakisd, Aurore Thibaute, Olivia Gosseriese, Gianfranco Lambertif, Enrique Noég, Sergio Bagnatoh, Brian L. Edlowi, Nicolas Lejeunej, Vigneswaran Veeramuthuk, Luigi Trojanol, Nathan Zaslerm, Caroline Schnakersn, Andrea Manninia,o, Alfonso Magliacanoa,o
aIRCCS Fondazione Don Carlo Gnocchi ONLUS, Florence, Italy, bScuola Superiore Sant’Anna, Istituto di BioRobotica, Pontedera, Italy, cFondazione Santa Lucia IRCCS, Rome, Italy, dNeurosurgery Dept, University of Athens Medical School, Athens, Greece, eComa Science Group, GIGA Consciousness, University and University Hospital of Liège, Liège, Belgium, fNeurorehabilitation and Vegetative State Unit E. Viglietta, Cuneo, Italy, gIRENEA-Instituto de Rehabilitación Neurológica, Fundación Hospitales Vithas, Valencia, Spain, hUnit of Neurophysiology and Unit for Severe Acquired Brain Injuries, Rehabilitation Department, Giuseppe Giglio Foundation, Cefalù, Italy, iCenter for Neurotechnology and Neurorecovery, Dept of Neurology, Massachusetts General Hospital, Boston, USA, jCHN William Lennox, Ottignies, Belgium, kDivision of Clinical Neuropsychology, Thompson Hospital Kota Damansara, Selangor, Malaysia, lDepartment of Psychology, University of Campania “L. Vanvitelli,” Caserta, Italy, mConcussion Care Center of Virginia, Ltd., Richmond, USA, nResearch Institute, Casa Colina Hospital and Centers for Healthcare, Pomona, USA
ABSTRACT
Background: After severe acquired brain injuries, some patients remain in a condition of prolonged Disorder of Consciousness (pDoC; i.e., Vegetative State/Unresponsive Wakefulness Syndrome, VS/UWS, or Minimally Conscious State, MCS). Clinical diagnosis at admission, usually confirmed by the Coma Recovery Scale-Revised (CRS-R), conveys prognostic information since patients in MCS often show a more favorable clinical outcome than patients in VS/UWS. Recently, we derived a composed index from the CRS-R sub-scales by means of an unsupervised machine-learning approach (i.e., the Consciousness Domains Index, CDI). We suggested that categorizing pDoC patients into two clusters according to the CDI improved the prediction of the full consciousness recovery at six months post-injury, compared to classifying patients based on their clinical diagnosis at admission.
Here, we applied CDI on a different sample with two aims: a) to externally validate the prognostic accuracy of the CDI with respect to the clinical diagnosis of VS/UWS or MCS at admission; b) to investigate prediction accuracy on long-term outcomes at different follow-ups, i.e. 6, 12 and 24 months post-injury.
Methods: Data on pDoC patients enrolled in an international IBIA DoC-SIG multicenter longitudinal study were retrospectively analyzed. Inclusion criteria were: age> 18, diagnosis of pDoC due to a traumatic or non-traumatic injury, time post-onset between 1 to 3 months after the event. We considered as primary outcome the recovery of full consciousness at 6, 12 and 24 months post-onset.
After deriving K-means++ clusters centroids on a first dataset, the CDI was validated on the IBIA DoC-SIG dataset. Chi-square tests were conducted to assess association of the outcomes with both the CDI and the clinical diagnosis at admission.
Results: A total sample of 144 patients with pDoC were included in the study (102 males; median age = 53 [IQR = 36] years) of whom 74 were in MCS.
Patients were significantly younger (p = 0.003) and had a significantly longer time post-onset (p < 0.001), than those enrolled in the first study. No significant differences were found between the two datasets in terms of sex, clinical diagnosis at admission, and CRS-R sub-scores (p > 0.05).
The present study showed that CDI and clinical diagnosis at admission were significantly associated with the outcome at 6, 12 and 24 months (p < 0.001). However, the CDI showed a higher univariate prediction accuracy, compared to clinical diagnosis at admission, at six (accuracy = 80% vs. 75%), twelve (80% vs. 74%), and twenty-four (78% vs. 73%) months post-onset.
Conclusion: Unsupervised machine-learning approach on multi-dimensional scoring of the CRS-R sub-scales may improve neurological prognosis of patients with pDoC with respect to the clinical diagnosis at admission. A more accurate prognosis would help physicians and caregivers on decisions about patient’s management and care pathways plan.
Acknowledgments: This project was funded by the H2020-MSCA 778234-DoCMA project).
520 A case study of a 15-year-old female swimmer with multiple concussions complicated by autonomic dysfunction (postural orthostatic tachycardia syndrome), dystonia, gait instability and migraine
Marguerite Moorea, Christa Hubbarda,b
aNorthern Michigan University, Marquette, USA, bHorizon Healthworks, Canton, USA
ABSTRACT
Context: Patients with multiple comorbidities are challenging to treat following a concussion due to overlapping symptoms. Medications and their side effects may further complicate the presentation.
History: This complex case of a 15-year-old with multiple comorbidities presented to our clinic after seeing several specialists and taking five prescriptions without relief. Due to four diagnosed concussions in the past three years, two in the past four months, the patient no longer attended school, slept 12+ hours per day, and drastically reduced physical activity due to intolerance. Primary complaints: dizziness, intractable headache, difficulty concentrating, intermittent weakness, fatigue and back/neck pain.
Methods: Dizziness Handicap Inventory (DHI) scores of 48 (16 physical, 10 emotional, 22 functional), Sports Concussion Assessment Tool (SCAT-5) symptom scores of 15/22, severity 59/132, symptoms exacerbated by physical/mental activity, and reported feeling 50% of normal. Vestibular/Ocular-Motor Screening (VOMS) scores indicated smooth pursuits (+2 saccadic pursuits bilaterally, greater saccadic intrusions to the left than right), Vertical saccades (+2 with left head tilt), Vestibular Ocular Reflex (VOR) Vertical (+4 excessive blinking, and muscular spilling to anterior neck and shoulders), VOR Horizontal (cervical dystonia left greater than right particularly during left head turns), Visual Motion Sensitivity (+2). During gait, excessive weight shift to left on left stance, worse during head rotated to the left position for eyes open/closed forward and backward walking. During gait in head left position, particularly on left stance, she laterally elevated her right arm to stabilize as a righting response.
Treatments: Visual, vestibular, neurological, cognitive therapies. Over nine months of therapy patient was additionally treated for: posterior canal BPPV in her left ear, persistent left sided cervical and proximal shoulder dystonia with task specific right sided cervical and upper shoulder dystonic spreading during task specific activities (left finger to nose and left stance during gait), and the Levine Protocol for Postural Orthostatic Tachycardia Syndrome.
Outcome: Patient eliminated all pain medicine and side effects with a significant decrease in pain in her low back (intermittent and 0–2/10), and 0 in neck, right shoulder. SCAT-5 symptoms scores 6/22, severity 12/132, with no physical or mental exacerbation and felt 80% of normal, VOMS (normal), DHI (physical 2, emotional 2, functional 0). Patient returned to normal social/sport activities and plans to attend school in person next semester.
Discussion: Patient exhibited greater muscle tonus in her left quad and a greater bias of weight shifting to the left side. Post-concussion she shifted her weight to the left to the point she exhibited lateral pulsion to the left during gait. For swimming, the patient flip turns to the left which is associated with asymmetric vestibular activity which is a bias created by sports and may be associated with increased severity of symptoms and prolongation of recovery.
521 Covert command-following in disorders of consciousness: findings and implications for clinical practice from an international cohort study
Yelena Bodiena,b, Judith Allansonc, Paolo Cardoned,e, Emmanuel Stamatakisf, Arthur Bonhommed,e, Jerina Carmonag, Camille Chatelled,e, Srivas Chennuf, Mary Conteh, Stanislas Dehaenei, Paola Finoiaf, Gregory Heinoneng, Phoebe Lawrenceb, Anogue Meydanb, Benjamin Rohautj, William Sandersb, Jacobo Sittj,k, Andrea Soddul, Mélanie Valentej, Angela Velazquezg, Athina Vrosgoug, Jan Claasseng, Brian Edlowb, Joseph Finsh, Olivia Gosseriesd,e, Steven Laureysd,e, David Menonf, Lionel Naccachej,k, Adrian Owenm, John Pickardf, Aurore Thibautd,e, Jonathan Victorh, Joseph Giacinoa,b, Emilia Bagiellan, Nicholas Schiffh
aSpaulding Rehabilitaiton Hospital, Harvard Medical School, Charlestown, USA, bMassachusetts General Hospital, Harvard Medical School, Boston, USA, cAddenbrookes Hospital, Cambridge, United Kingdom, dComa Science Group, GIGA-Consciousness, University of Liège, Liège, Belgium, eCentre du Cerveau, Liège, Belgium, fUniversity of Cambridge, Cambridge, United Kingdom, gColumbia University Medical Center, New York Presbyterian Hospital, New York, USA, hWeill Cornell Medical College and New York Presbyterian Weill Cornell Medical Center, New York, USA, iUniversité Paris-Sciences-Lettres, Paris, France, jBrain institute-ICM, Inserm U1127, CNRS UMR 7225, Sorbonne Université, France, kAssistance Publique – Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Departments of Clinical Neurophysiology and of Neurology, France, lWestern Institute for Neuroscience, Physics & Astronomy Department, University of Western Ontario, London, Canada, mWestern Institute for Neuroscience, Department of Physiology and Pharmacology and Department of Psychology, University of Western Ontario, London, Canada, nIcahn School of Medicine at Mount Sinai, New York, USA
ABSTRACT
Objective: Nearly two decades of work support early theories that some individuals who sustain a severe brain injury may retain conscious awareness that is not detected on bedside assessment
We assembled an international consortium of clinicians and investigators to prospectively estimate the incidence of covert command-following (CCF) in persons with disorders of consciousness (DoC) who do not follow commands on bedside assessment.
Methods: We report preliminary data from a convenience sample of 289 participants with acute and chronic DoC enrolled in the United States, United Kingdom, Belgium, and France between 2009–2022. Legal surrogates provided consent to include results of local studies in our centralized database. We defined CCF as no evidence of command-following on the Coma Recovery Scale-Revised (i.e, CRS-R; auditory subscale < 3 and visual subscale < 5) but evidence of command-following on statistically validated EEG and/or fMRI responses to an active paradigm (e.g., imagine playing tennis). Investigators analyzing the fMRI and EEG data were blind to behavioral diagnosis and vice-versa. In this pragmatic real-world study, which utilized common design and data elements, data acquisition parameters and analytic approaches varied across sites.
Results: Of 194 participants with no evidence of command-following on the CRS-R (mean[SD] age = 47[18] years, 58% male, 63% non-TBI, 475[1105] days post-injury, 35% ≤ 28 days post-injury) and at least one attempted active fMRI (n = 103) and/or EEG (n = 154) paradigm, 39 (20%) demonstrated CCF by at least one method. CCF was observed using fMRI in 25 (24%) and EEG in 18 (12%) participants. Data were uninterpretable (e.g., due to motion, technical or other factors) for 9 (9%) participants with fMRI and 7 (5%) with EEG assessments. Of 95 participants with command-following on the CRS-R (age = 44[17] years, 73% male, 42% non-TBI, 604[907] days post-injury, 23% ≤ 28 days post-injury), and at least one attempted active fMRI (n = 69) and/or EEG (n = 67) paradigm, 34 (36%) demonstrated command-following by at least one of these two methods. Command-following was observed on fMRI in 23 (33%) and on EEG in 15 (22%) participants.
Conclusions: In a large international cohort of persons with DoC, fMRI and EEG detected CCF in a substantial proportion of patients with no behavioral evidence of command-following. Consistent with prior studies, there was also a high rate of false negative findings (no CCF in patients who follow commands behaviorally). Clinical implementation of fMRI and EEG for detecting CCF is recommended by professional organizations, but, widespread deployment of these techniques has not yet been achieved. These observations reinforce results from smaller single-site studies and further raise concern that, worldwide, a large group of persons with preserved awareness may not be recognized as such. Detecting CCF in persons with DoC may substantially impact clinical management and promote interpersonal interactions, ultimately facilitating patient autonomy.
522 Feasibility and validity of the coma recovery scale revised for accelerated standardized testing (CRSR-FAST) in the intensive care unit
Yelena Bodiena,b, Isha Vorac, Alice Barrad,e, Kevin Changb, Camille Chatelled,e, Kesley Goostreya, Christopher Malonea, Geraldine Martensd,e, Ally Sterlinga, Abigail Watersa, Ron Hirschberga,b, Doug Katzf,g, Nicole Mazwib, Brian Edlowb, Joseph Giacinoa,b
aSpaulding Rehabilitaiton Hospital, Harvard Medical School, Charlestown, USA, bMassachusetts General Hospital, Harvard Medical School, Boston, USA, cMassachusetts General Hospital Institute of Health Professions, Boston, USA, dComa Science Group, GIGA Consciousness – GIGA Research, University of Liège, Liège, Belgium, eCentre du Cerveau, University Hospital of Liège, Liège, Belgium, fEncompass Health Braintree Rehabilitation Hospital, Braintree, USA, gBoston University School of Medicine, Boston, USA
ABSTRACT
Objective: The Coma Recovery Scale-Revised (CRS-R) is a standardized assessment instrument developed to monitor recovery in persons with disorders of consciousness (DoC) and recommended, by multiple professional organizations, for clinical management of persons with DoC. However, CRS-R assessment can require 20–40 minutes, making it impractical for consistent use in the Intensive Care Unit (ICU). We developed and tested the feasibility, reliability, and validity of the CRS-R For Accelerated Standardized Testing (CRSR-FAST), a short form of the CRS-R for use in the ICU. The CRSR-FAST consists of five items, (i.e., command-following, visual fixation/pursuit, automatic motor responses, localization to noxious stimulation and intelligible verbalization) that, based on prior studies, are likely to be the first signs of consciousness to emerge after severe brain injury.
Methods: Of 55 consecutively enrolled patients with traumatic DoC receiving care in the ICU, 44 completed the study. Three trained examiners administered one CRS-R and three CRSR-FAST assessments in a randomized order over two consecutive days. Examiners were blind to the participants’ clinical diagnosis and preceding CRS-R and CRSR-FAST assessments, except during assessment of test-retest reliability. For patients receiving continuous sedation, assessments were conducted after sedation was weaned. We investigated the feasibility of administering the CRSR-FAST by monitoring the duration of the evaluation (target ≤ 10 minutes). We evaluated the concurrent validity of the CRSR-FAST by comparing the results (i.e., conscious versus unconscious) to the full-length CRS-R. We also evaluated interrater and test-retest reliability. Consent for study participation was provided by surrogate decision-makers.
Results: Of 44 participants, one was excluded due to confounds to the examination resulting from polytrauma. In the remaining 43 participants (mean [SD] age = 42 [20] years, 69% male, 9 [6] days post injury, CRS-R Total Score = 7 [6], 40% coma or vegetative state, 60% minimally conscious state) mean [SD] CRSR-FAST administration time was 7 [3] minutes versus 20 [7] minutes for the CRS-R. CRSR-FAST diagnostic ratings agreed with CRS-R ratings in 84% of the sample (i.e., concurrent validity). In the 7 participants for whom the ratings differed, the CRS-R detected consciousness in 5 cases where the CRSR-FAST did not, despite the behavior contributing the diagnostic rating of “conscious” being present on both scales. Diagnostic ratings were the same for the CRSR-FAST administered by two different examiners in 93% of participants (i.e., inter-rater reliability) and for the CRSR-FAST administered twice by the same examiner in 87% of participants (i.e., test-retest reliability).
Conclusions: Our preliminary data indicate that the CRSR-FAST is a feasible, reliable, and valid tool for assessing consciousness in the ICU. The CRSR-FAST may improve diagnostic accuracy in the ICU, which would facilitate clinical decision-making regarding continuation of life-sustaining therapy, aid disposition planning, and improve care coordination between acute and post-acute care providers.
523 Validity of the telephone versions of the coma recovery scale revised (CRS-R) and confusion assessment protocol (CAP) for standardized remote assessment of disorders of consciousness
Yelena Bodiena,b, Ally Sterlinga, Andrea Christoforoua, Michael Bergina, Geraldine Martensc,d, Rebecca Nardullia, Pengsheng Nie, Therese O’Neil-Pirozzia, Joseph Ostrowa, William Sandersa, Amber Thomasa, Abigail Watersa, Flora M. Hammondf, Risa Nakase-Richardsong,h, Justin O’Rourkei, Mark Shererj, Joseph Giacinoa,b
aSpaulding Rehabilitaiton Hospital, Harvard Medical School, Charlestown, USA, bMassachusetts General Hospital, Harvard Medical School, Boston, USA, cComa Science Group, GIGA Consciousness – GIGA Research, University of Liège, Liege, Belgium, dCentre du Cerveau, University Hospital of Liège, Liege, Belgium, eBoston University, Boston, USA, fIndiana University School of Medicine, Indianapolis, USA, gJames A. Haley Veterans’ Hospital, Tampa, USA, hMorsani College of Medicine at the University of South Florida, Tampa, USA, iSouth Texas Veterans Health Care System Polytrauma Rehabilitation Center, San Antonio, USA, jTIRR Memorial Hermann, Houston, USA
ABSTRACT
Objective: We developed and evaluated the validity of telephone versions of two measures used to assess consciousness and the confusional state: the Coma Recovery Scale-Revised (CRS-R) and the Confusion Assessment Protocol (CAP), respectively. The CRS-R and CAP must currently be administered in-person, making it difficult to monitor long-term functional outcome accurately and consistently. The need for a validated approach to remote assessment of consciousness and symptoms of confusion became even more urgent in the wake of the COVID-19 pandemic.
Methods: We developed a telephone CRS-R and/or CAP interview based on items that differentiate patients in a vegetative state from those in a minimally conscious state (CRS-R) and items that assess basic cognition and orientation (CAP-Cog). Enrolled across five sites in the United States, a convenience sample of 31 persons with DoC and their caregivers completed an in-person CRS-R and/or CAP (persons with DoC) and a telephone CRS-R and/or CAP interview (caregiver). Examiners who administered the in-person assessments were blind to the telephone interview responses and vice-versa. We calculated the accuracy and corresponding 95% confidence intervals (CIs) for each of the 10 telephone CRS-R and 9 CAP-Cog questions. We defined accuracy as the frequency with which the caregiver and study staff examiner assigned the same rating for each behavior assessed. We calculated the average score of the 19 Patient Outcome questions and assessed the agreement between caregiver and staff ratings using Lin’s concordance correlation coefficient (CCC) with 95% CIs. We used the in-person examination as the reference standard for all analyses and set the cut-point for acceptable agreement at 0.70.
Results: The average accuracy of the 10 CRS-R and 9 CAP-Cog telephone-based questions for the sample (n = 31, mean [SD] age = 54 [12] years; 68% female; 32% 1-year, 45% 2–5 years, and 13% >5 years post injury) was 0.79 and 0.86, respectively. Accuracy values met or exceeded the 0.70 cutoff on 9 of the 10 CRS-R questions (agreement range: 0.70 [CI: 0.54,0.86] to 0.93 [CI: 0.84,1.00]) and all 9 CAP-Cog questions (agreement range: 0.77 [CI: 0.62,0.92] to 0.93 [CI: 0.84,1.00]). Lin’s Concordance Correlation Coefficient for the average agreement between the caregiver and staff ratings across all 19 questions combined exceeded the 0.70 criterion for agreement (0.87 [CI: 0.78,0.96]).
Conclusions: Our results provide preliminary evidence for the validity of the telephone CRS-R and CAP-Cog. Systematic, serial, and standardized long-term assessment of consciousness is fraught with barriers (i.e., transportation, medical instability, and access) related to in-person evaluation. The expansion of remote services offered through tele-health clinics and an evolving literature on the likelihood of regaining independence even years after severe brain injury suggest the need for tools that remotely monitor subtle changes in recovery from DoC.
524 Changes in patterns of dual-task interference in active duty service members with mtbi following rehabilitation
Courtney Harrisona, Rachana Gangwania, Crystal Ramseya, Karen McCullocha
aUniversity Of North Carolina At Chapel Hill, Chapel Hill, USA
ABSTRACT
Background: The Portable Warrior Test of Tactical Agility (POWAR-TOTAL), a performance-based dual-task (DT) assessment, was designed for use by physical therapists to aid in return-to-duty recommendations. The motor component includes rapid position changes while carrying a simulated weapon, and the cognitive component requires memorization of an eight-character grid coordinate (e.g., Echo-Bravo 5-2-3-9-4-1). Each component is measured in a single-task trial, and then were combined for 3 DT trials. Healthy control (n = 59) scores were also analyzed as a reference.
Methods: Pre-post therapy assessments were conducted on 46 active-duty service members (SM) who were seeking treatment for persistent post-concussion symptoms at Intrepid Spirit Centers. The average age in the pre-post group was 29.1 years (SD = 6.3), and the average time between assessments was 91.2 days (SD = 64.6). Mean performance scores for the 3 trials of both the cognitive and motor components of the DT assessment were used to quantify pre-post therapy changes. The relative DT effect was calculated to identify performance trade-offs and prioritizations associated with DT cost. The relative DT effect scores were plotted on a quadrant graph, and categorization was defined by the SMs location on the grid. The 9 categories were cognitive interference, cognitive facilitation, motor interference, motor facilitation, motor priority trade-off, mutual interference, mutual facilitation, cognitive priority trade-off, and no interference. No interference was defined as SMs who had less than 10% decrement in performance for cognitive and motor scores. Pre- and posttest scores were compared using paired sample t-tests, and a p-value of less than 0.05 was considered statistically significant.
Results: A paired sample t-test was performed to examine the relationship between the motor and cognitive relative DT scores for pre (motor: M = 0.02, SD = 0.10; cognitive: M = 0.02, SD = 0.42) and post (motor: M = 0.02, SD = 0.07); cognitive: M = −0.06, SD = 0.28), however the results were not statistically significant (motor: t(45) = −0.4, p = 0.69; cognitive: t(45) = 1.1, p = 0.28). More SMs with mTBI prior to intervention demonstrated cognitive interference (32.6%) than any other pattern of interference. SMs with mTBI post-intervention demonstrated trends similar to the healthy control peers, with a shift to ‘no interference’ (39.1%) as the largest group and cognitive interference as the second largest group (30.4%) after treatment.
Conclusion: SMs seeking intervention for mTBI demonstrated greater cognitive task interference prior to intervention, implying a priority on the motor task. After intervention, the most common response to the dual-task test was no interference as characterized by dual-task effects for cognitive and motor performance below a 10% threshold, suggesting improvements in dual-task performance for the largest subgroup in the sample. Military culture innately values physical performance which likely contributes to a focus on motor skills over cognitive skills in dual-task scenarios, a pattern that was also observed in the healthy control comparison group.
525 Being technical about the tackle … . the landscape of suspected concussive tackle events in female varsity rugby union
Isla Shilla,b, Stephen W. Westa,c, Sharief Hendricksd, Brent E. Hagela,c,e,f,g, Carolyn A. Emerya,b,c,e,f,g,h
aSport Injury Prevention Research Center, Faculty of Kinesiology, University Of Calgary, Calgary, Canada, bHotchkiss Brain Institute, University of Calgary, Calgary, Canada, cO’Brien Institute of Public Health, University of Calgary, Calgary, Canada, dDivision of Physiological Sciences and Health, Physical Activity, Lifestyle and Sport (HPALS) Research Center, Department of Human Biology, Faculty of Health Sciences, the University of Cape Town and the Sports Science Institute of South Africa, Cape Town, South Africa, eAlberta Childrens’ Hospital Research Institute, University of Calgary, Calgary, Canada, fDepartment of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada, gDepartment of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada, hMcCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
ABSTRACT
Background: Participation in female rugby union has grown, however, few studies exist in sub-elite and youth female populations. Consistent with other rugby populations, the tackle is the most common match event and accounts for the largest proportion of concussions. To improve safety in the sport, video-analysis has been used in elite male rugby to identify risk factors for tackle-related concussion to inform law changes (such as lowering tackle height) and injury prevention programmes. Similar video analyses studies however do not exist in female rugby.
Objectives: To describe tackle and head impact characteristics of suspected concussive tackle events in Canadian female varsity rugby union.
Methods: A cross-sectional video analysis study was completed using three seasons of match footage from the CanWest female varsity rugby league. Forty-eight games had been coded for match events. Suspected concussions were identified and validated by expert clinicians and rugby injury researchers. Thereafter, concussive tackle events were coded for tackle and head impact characteristics. Head impact characteristics were described for the main head impact within the tackle. An ordinal head impact intensity scale was used to quantify the intensity of head contact (1: Unaffected head position; 2: Light contact with minimal head movement; 3: Moderate contact completely affecting head; 4: Heavy contact totally affects head).
Results: Forty-six suspected concussions occurred in 45 tackle events. 25/46 concussions were sustained by ball carriers (54%) and 20/46 (44%) tacklers. One concussive event resulted in two players with suspected concussions. Twenty-nine percent (13/45) of concussive tackle events involved two or more tacklers [Two tacklers: 11(24%); Three tacklers: 2(4%)]. The most common tackle types were shoulder (34/46, 74%) and smother (6/46, 13%). For concussed ball-carriers, 72% (6/25) had upright and 24% (6/25) bent-at-waist body position. Additionally, 60% (15/25) had “up and forward” and 20% (5/25) “away” pre-contact head position. For concussed tacklers, 62% (13/21) had bent-at-waist and 33% (7/21) had upright body position. Additionally, 95% (20/21) had “up and forward” pre-contact head position. Seventy-six (35/46) percent of players with a suspected concussion sustained at least one observed head impact on video. Forty-nine percent (17/35) of main head contacts were a result of head hitting ground and 34% (12/35) were a result of head contacting a part of the opponent (i.e., head, shoulder, upper leg, torso/hip). For suspected concussions where a head impact intensity could be evaluated (33/46), 61% (20/33) were deemed to be three or four.
Conclusions: Suspected concussions are a result of different tackle and head contact characteristics. Risk factor analyses to explore the association between concussive tackle events and tackle characteristics are needed to inform primary prevention strategies (e.g., tackle training programs, tackle law change) to reduce concussion rates in female rugby.
527 The relation between DNA markers and level of consciousness in patients with severe acquired brain injury: preliminary data
Maya Kandahb, Jeanette Gumaranga, Emily Rosarioa, Zhong Sheng Zhenga, David Pattersona, Elbert Changa, Gary Jensena, Christopher Mantika, Neha Dhadwala, Martin Montic, Caroline Schnakersa,c
aCasa Colina Hospital and Centers for Healthcare, Pomona, USA, bFlorida Atlantic University, Boca Raton, USA, cUniversity of California Los Angeles, Los Angeles, USA
ABSTRACT
Background: Severe acquired brain injury may result in substantial cognitive and physical impairments associated with disorders of consciousness (DOC). Prior research suggests that presence of DNA markers, such as brain-derived neurotrophic factor (BDNF), apolipoprotein E4 (ApoE4), and catechol-O-methyltransferase (COMT), influence patients’ recovery after severe acquired brain injury. However, the full extent of these DNA markers and their implications in patients with DOC are not well understood. Specifically, it is not clear which genomic variations are associated with unfavorable outcome after severe brain injury and resulting in prolonged DOC.
Objective: The objective of this study is to review the main genetic markers associated with recovery after severe acquired brain injury and to investigate the presence of these markers in a small population of chronic DOC patients in order to gather preliminary information on polymorphisms associated with poor outcome following severe acquired brain injury.
Methods: Salivary samples from 8 patients with severe acquired brain injury were collected using 23andMe kits and raw genotype data was provided after analysis through secured e-mail. Specifically, rs6265 (BDNF), rs7412 and rs429358 (ApoE4), and rs4680 (COMT) were investigated to determine the presence of specific alleles and their frequency in patients with DOC.
Results: In our sample, we successfully collected data in eight patients (4 male, age: 35 ± 18y, 5 TBI, 2 anoxia, 1 hemorrhagic stroke, time since injury: 1205 ± 774 days). All eight patients had genes associated with BDNF, ApoE4 and COMT. For BDNF (rs6265), 55% of the patients presented alleles associated with poor outcome (11% with alleles TT, 44% with alleles CT). Additionally, for COMT 55% of patients also had alleles associated with poor outcome (22 with alleles GG and 33% with AG). Lastly, only 2 patients (22%) had a C allele at both rs7412 and rs429358, indicating presence of ApoE4.
Conclusion: These findings are preliminary; however, our results indicate that BDNF and COMT are the most frequently detected DNA markers in patients with prolonged DOC. The presence of genetic polymorphisms may play a role in outcome following severe acquired brain injury and resulting in prolonged DOC.
528 Hear our voice: the creation of a young person’s advisory group for the national acquired brain injury learning and education syndicate (NABLES)
Gemma Costelloa,b, Emily Bennetta,c, Chloe Haywarda
aNational Acquired Brain Injury Learning and Education Syndicate, London, United Kingdom, bCambridge Center for Pediatric Neuropsychological Rehabilitation, Cambridge, United Kingdom, cNottingham Childrens Hospital, Nottingham, United Kingdom
The National Acquired Brain Injury Learning and Education Syndicate (NABLES) was established in 2019 following the publication of the Time for Change report (All Party Parliamentary Group, 2018). To date the objectives of NABLES have been to raise awareness of ABI in education, to influence policy and the development of national pathways. The group has consisted of a range of professionals from across education, health, voluntary sector and parents with children who have lived experience of ABI. As a group we acknowledge that the voices of children and young people are often missing from policy, research and national guidance, recognizing the strengths that models of coproduction have to drive change and influence our learning from those with lived experience. The intention is to mitigate against the lack of pediatric voices which have been deemed to result in an incomplete evidence base from which to inform clinical rehabilitation practice (Mah et al., 2019). NABLES recognized the need to coproduce future projects and steer the direction of our work with children and young people with lived experience of ABI. We therefore sought to recruit children and young people to our advisory group. We hoped this forum would elevate their stories and voices to drive forward change. This group has recently formed and they have highlighted key issues for them and shared their thoughts on future directions for NABLES. They have also agreed key objectives for their group and advised on how we measure our success and outcomes. This newly appointed advisory group has much to offer in driving forward strategic change. They are keen to have their voices heard and influence the field through sharing their ideas.
529 Changes in nREM sleep duration following thalamic low intensity focused ultrasound pulsation: preliminary data
Caroline Schnakersa,c, Rohan Chawlab, Jeanette Gumaranga, Emily Rosarioa, David Pattersona, Elbert Changa, Gary Jensena, Christopher Mantika, Neha Dhadwala, Martin Montia
aCasa Colina Hospital and Centers for Healthcare, Pomona, USA, bWestern University of the Health Sciences, Pomona, USA, cUniversity of California Los Angeles, Los Angeles, USA
ABSTRACT
Background: There are currently no approved treatments to bolster recovery in patients with disorders of consciousness (DoC; i.e, vegetative state – VS – or minimally conscious state – MCS). Thalamic Low Intensity Focused Ultrasound Pulsation (tLIFUP) has recently been investigated as a novel noninvasive neuromodulation approach.
Objective: nREM sleep elements such as K-complexes and sleep spindles have generators in the thalamus and their presence has previously indicated better outcomes for patients with DoC. We assessed whether tLIFUP could increase nREM in patients with DoC and whether changes to nREM sleep could relate to behavioral improvement.
Methods: The sleep patterns of nine patients classified as being MCS or VS based on the Coma Recovery Scale-Revised (CRS-R) were analyzed. Participants’ ages ranged from 21 to 69 years; etiologies mostly included traumatic brain injuries (n = 5); and time since injury ranged from two to seven years. Nocturnal polysomnography (PSG) was recorded and automatically scored using the Dreem2 headband based on frontal (Fp1, F7, F8) and occipital (O1, O2) electrodes. Percentage of sleep spent in nREM the night before tLIFUP vs. prior to discharge were compared using paired t-test. The changes in nREM percentage were also correlated to changes in CRS-R scores after LIFUP.
Results: A significant increase (on average 22.3%) was observed in the amount of nREM sleep following tLIFUP (t = 0.75; p = 0.02). However, the Spearman correlation between changes in nREM sleep and CRS-R scores was not significant (r = 0.20; p = 0.59). Factors such as age, etiology, and time since injury did not significantly affect the percent change in nREM sleep.
Conclusion: These preliminary data suggest that tLIFUP could promote nREM sleep and have therapeutic considerations for individuals with DoC.
530 A profile of the physiotherapy needs of patients presenting with subarachnoid hemorrhage on the acute neurosurgical wards, in the national center for neurosurgery in Ireland
Fiona Kinsellaa, Niamh Bergina, Deirdre Coffeya, Mohsen Javadpoura
aBeaumont Hospital, Dublin, Ireland
ABSTRACT
Introduction: Non-traumatic subarachnoid haermorrhage (SAH) from ruptured aneurysm accounts for approximately 5–6% of all strokes (Martin 2011). Similar to cerebral infarcts, this patient population often requires multidisciplinary rehabilitation to improve their quality of life and restore function. Despite similarities in clinical presentation, patients presenting post SAH often have difficulty accessing the pathways and guidelines recommended by The Irish Heart Foundation for cerebral infarcts, such as Early Supported Discharge (ESD) services.
Aim: To profile the patients referred to the acute neurosurgical physiotherapy service following a SAH in Beaumont Hospital, in order to understand their rehabilitation needs and provide insight to support future service planning.
Methods: Prior to commencement, this patient profile was registered and approved by the local Clinical Audit Registry in Beaumont Hospital. Patients admitted to the acute neurosurgical ward with SAH from 1st September 2022 to 30th September 2022, were included in this profile. To accurately capture the data, a centralized database of admissions to the national neurosurgical service was reviewed to identify patients presenting with SAH. Data points including age, sex, surgical intervention, day of referral to physiotherapy service, mobility status on initial assessment, number of physiotherapy interventions, mobility status on discharge and discharge destination were collected. Patients admitted with traumatic SAH were not included.
Results: A total of 14 patients were admitted with a SAH to acute neurosurgical ward-based care during the month of September 2022 and 57% (n = 8) of these patients were referred to physiotherapy. Of the patients referred to physiotherapy, 75% (n = 6) were female and 25% (n = 2) were male. Two thirds of the patients referred for physiotherapy also required admission to the Intensive Care Unit (ICU) over the course of their inpatient stay. Ages ranged from 38 to 81 years with a mean age of 61 years. Individual’s level of dependency varied with n = 4 requiring single, n = 3 double and n = 1 multiple supports. In this sample of 8 patients there were 22 physiotherapy interventions, with a mean of 2.75 interventions delivered to this cohort. Following discharge from acute neurosurgical care, 75% of these patients required further medical and/or rehabilitation intervention, and therefore were transferred to their referring hospital. Of the remaining two patients, n = 1 discharged directly home and n = 1 patient died.
Conclusion: This profile, although a small sample size, highlights the varying physiotherapy needs of this population and the demands on the acute neurosurgical ward-based physiotherapy service. Consideration for future resource allocation and development of local rehabilitation pathways must consider the wide and varied range of this population’s needs, in order to meet best practice guidelines for improved quality service. In addition, future reprofiling projects should focus on evaluating the factors limiting physiotherapy intervention and possible suitability of follow up options, such as ESD.
531 Phenotyping depression after mild traumatic brain injury: evaluating the impact of multiple injury and injury context
Eamonn Kennedya,b,c, Mustafa Ozmena,d, Erin D. Bouldina,b, David F. Tatea,c, Elisabeth A. Wildea,c, M J Pugha,b
aVA Salt Lake City Health Care System, IDEAS Center, Salt Lake City, USA, bDivision of Epidemiology, University of Utah School of Medicine, Salt Lake City, USA, cDepartment of Neurology, University of Utah School of Medicine, Salt Lake City, USA, dDepartment of Electrical and Electronics Engineering, Antalya Bilim University, Antalya, Turkey
ABSTRACT
The psychological consequences of mild traumatic brain injury (mTBI) are a leading cause of disability among mTBI survivors. Yet little work has explored how the number of injuries or the context of injury (vehicular accidents, violence, falls, etc.) may compound risk for mental health outcomes, including major depression. Here, we report results to date from the Long-term Impact of Military-relevant Brain Injury Consortium (LIMBIC) Prospective Longitudinal Study (PLS) that evaluates how the number and context of historical mTBIs are associated with moderate depression, defined as a score above 10 on the Patient Health Questionnaire-9 (PHQ-9) among US Veterans. We report a phenotyping approach, where natural language processing of event-level descriptions are used to broaden understanding of risk associated with different injury contexts. Relative to Veteran controls with no history of potential concussive events (PCEs) or mTBIs (N = 567), Veterans with one mTBI (N = 378) showed significantly higher odds for moderate depression (OR: 1.41, CI95% [1.13–1.68]). This association persisted for higher severity cutoffs and after adjusting for sociodemographic and military covariates. Veterans with history of two or more mTBIs (N = 651) showed significantly higher odds for moderate depression compared to controls (OR: 1.73 [CI95% 1.41–2.05]). A dose response indicated number of mTBIs was also significantly (p < 0.05) associated with depression score after covariate adjustment. Categorical context of injury was also found to be significantly associated (p < 0.05) with depression measures. This work suggest personalized approaches to treatment and further research into etiological considerations may offer benefits and improved quality of life for Veterans living with mTBI.
532 Traumatic brain injury (TBI) in Ireland: pathways through rehabilitation
Kate O’Donnella,b, Andrea Healya,b, Anthony Stainesa, Catherine Corrigana, Teresa Burkea, Brian Waldronb, Grainne McGettrickb
aDublin City University, Dublin, Ireland, bAcquired Brain Injury Ireland, Dublin, Ireland
ABSTRACT
Background: TBI is a leading cause of death and disability worldwide. Timely access to rehabilitation following moderate to severe brain injury is essential to optimize recovery, however very little is known about rehabilitation pathways for brain injury survivors in Ireland.
Method: A 2.5 year mixed-methods, observational study was used to investigate the rehabilitation pathways of moderate to severe TBI survivors (N = 121). Participants were surveyed on two occasions six months apart and data was extracted from participants’ medical records.
Results: 45.83% (n = 55) reported accessing inpatient rehabilitation; 40.83% (n = 49) reported accessing outpatient rehabilitation; and 39.16% reported accessing community rehabilitation. 27.5% received no rehabilitation outside of the acute care setting. Waiting time (in days) for first access to rehabilitation in any setting varied substantially (M = 253.97; SD 425.89) in this sample. A Mann Whitney U test found no statistically significant difference in days waiting for first rehabilitation episode between participants who had more recent injuries (Mdn = 98.5, n = 52) and those with older (Mdn = 139, n = 35) injuries at the time of first survey, U = 831.5, z = −0.680, p = 0.497. Additionally, no statistically significant difference in days waiting for first rehabilitation episode was found between participants with moderate (Mdn = 81.5, n = 22), and severe (Mdn = 124, n = 62) injuries, U = 584, z = −0.997, p = 0.319; between participants living in urban (Mdn = 132, n = 59) and rural (Mdn = 98.5, n = 28) areas, U = 624, z = −1.835, p = 0.066; or between females (Mdn = 124, n = 22) and males (Mdn = 115, n = 65), U = 705.5, z = −0.093, p = 0.926. However, days waiting for first rehabilitation episode was statistically significantly higher in participants who were employed compared to those who were unemployed, prior to injury, U = 483, z = −2.435, p = 0.015.
Discussion: Access to rehabilitation for survivors of moderate to severe TBI is recommended by prior research. Access to rehabilitation services varied substantially for moderate to severe TBI survivors in this sample, with over one quarter receiving no rehabilitation after the acute care phase. Clear TBI rehabilitation pathways are necessary to support timely access to rehabilitation and optimize recovery. The findings of the current study suggest that a coherent brain injury rehabilitation pathway does not yet exist in Ireland.
533 Feasibility of implementing a peer mentor program for patients with traumatic brain injury (TBI) and their care partners in an inpatient and outpatient setting
Librada Callendera, Stephanie Calhouna, Faith Mezaa, Alyssa Pattersona, Simon Drivera, Rosemary Dubiela
aBaylor Scott and White Institute For Rehabilitation, Dallas, USA
ABSTRACT
Background: Peer mentors can help newly injured patients and families prepare for transition home and adjust to physical/cognitive challenges posed by traumatic brain injury (TBI). Evidence from spinal cord literature supports that peer mentors can help adjustment by providing emotional support and modeling ways to successfully manage and accomplish large and important life goals. The purpose of this project is to demonstrate feasibility of establishing a peer mentor program for patients with TBI and care partners at a large inpatient rehabilitation hospital.
Methods: A TBI Peer Mentor program was implemented since January 2021 at a large inpatient/outpatient rehabilitation center across four facilities in North Texas with partnership from a local TBI support group. A stakeholder group which included hospital administrators, clinicians, researchers, and community members with TBI lived experience and care partners was convened to garner buy-in, help with decision making, and review regular status updates. Standard operating procedures were developed to define roles and training requirements for peer mentor administrators with TBI lived experience, peer mentors with TBI lived experience and care partners, and clinicians/researchers. Three types of supports were offered through this program: weekly education sessions, bi-weekly support group sessions (both include patients/care partners from the inpatient/outpatient clinic and held in-person and virtually), and 1:1 mentor-mentee pairings. A REDCap database was utilized to document enrollment into the TBI Peer Mentor program, collect engagement and satisfaction information from participants, and store documentation of mentor-mentee encounters.
Results: Two peer mentor administrators with TBI lived experience were hired as part-time contractors to administer the program, and 13 peer mentors with TBI lived experience and 6 care partners became registered volunteers for the program. Thirty-seven education sessions have been delivered to date with an average attendance of 8 survivors with TBI and care partners. Education topics included anatomy, behavior/social changes, and coping strategies/resources. Twenty-seven group support sessions have been convened with an average attendance of 14 survivors with TBI and care partners. Fifteen survivors with TBI and 10 care partners elected to participate in 1:1 mentor-mentee engagement. Of patients or care partners who filled out a group session survey, 14/17 (82%) were ‘Satisfied’ or ‘Very satisfied’ with the session topics and length. Out of 7 mentees who filled out surveys, all 23 mentoring sessions (100%) rated ‘Good’ session satisfaction.
Discussion: Stakeholder support is critical to implementing a peer mentor program in a rehabilitation hospital setting. Peer mentor administrators with TBI Lived Experience have been successful with delivering the program, recruiting peer mentors/mentees, and maintaining adequate documentation. There was strong engagement among mentors, mentees, and clinicians to ensure successful administration of the program. Future investigative efforts should collect outcomes data (e.g., self-efficacy, healthcare utilization, satisfaction) to demonstrate clinical efficacy of this intervention.
534 Semantic future thinking in adults with moderate-severe traumatic brain injury
Annick Tanguaya, Victoria-Grace Padillaa, Sharice Clougha, Greta Melegab, Louis Renoultb, Melissa Duffa
aVanderbilt University Medical Center, Nashville, USA, bUniversity of East Anglia, Norwich, United Kingdom
ABSTRACT
The capacity to envision the future holds several benefits, for example to plan adequately, regulate emotions, and make optimal decisions. General knowledge about the world (i.e., general semantics; “I know that tax season happens in early Spring”) and personal knowledge (i.e., personal semantics; “I know that I love the beach”) play a critical role in the imagination of future events (D’Argembeau, 2020). A few studies suggest that a moderate-severe traumatic brain injury (TBI) can impair access to personal semantics and their elaboration. In this study, we extend previous findings through a novel task, an adapted Semantic Autobiographical Interview (SAI); its scope, method of assessment, and the inclusion of a future-oriented component confer unique advantages. Sixteen people with chronic moderate-severe TBI and eleven uninjured comparison participants completed the SAI. During the task, participants freely elaborated about public events that could occur during a life chapter (i.e., a general semantics conditions) and they also elaborated on what the life chapter might be from a personal standpoint (i.e., a personal semantics condition). A subsequent period of specific probing sought to elicit additional details reflective of multiple types of general and personal semantics. We scored responses using the Autobiographical Interview scheme (Renoult et al., 2020) to quantity the amount and types of details produced during each task. Preliminary findings indicate that future general and personal semantic information is sparse and less richly detailed in the TBI group relative to the uninjured comparison group. Consistent with reports of disruptions in temporal processing, as a group, participants with TBI estimated their future chapters to be slightly longer in duration and less distant in the future than their uninjured peers. The two groups did not differ in the valence or intensity of the emotions experienced during the task, nor level of effort, or the perceived personal relevance of what was discussed. Additionally, the two groups did not differ in the feeling of connection with their future self. These findings suggest that individuals with TBI may envision a future that lacks precision, despite the similarities between groups in the perceptions of their future selves and the task. Deficits in episodic memory and future episodic thinking are well documented in TBI. These findings advance our knowledge of post-TBI memory disorders by extending these disruptions to semantic future thinking. Future work examining semantic thinking across time (e.g., remote memory) and real and imagined events is warranted. This work adds to a growing literature suggesting that semantic and episodic memory may have shared neural correlates and can be impaired in tandem. Investigation of personal semantics in TBI provides a unique window into memory and into the dynamic work of identity (re)construction post-injury.
535 Assessing readiness of modified barium swallow study for patients in a disorder of consciousness
Erin Montgomerya
aThe Ohio State University Wexner Medical Center, Columbus, USA
ABSTRACT
Assessment of behavioral and motor responses in context of dysphagia evaluation to determine readiness of an instrumental swallow study, such as a modified barium swallow study for patients in a disorder of consciousness state. Patients in a disorders of consciousness (DOC) benefit from the assessment and treatment of skilled professionals such as speech language pathologist (SLP). A SLP has the skill set to assess current swallow function, provide impairment-based neurorehabilitation therapy, and determine appropriateness of instrumental assessment. Dysphagia or swallowing difficulty is highly prevalent in patients suffering from a DOC. Oropharyngeal swallow function can be separated into two components: bolus efficiency and airway protection. Traditional medical focus of swallow function in patients with brain injuries is often on aspiration and penetration of oral secretions and PO bolus. This is what is related to the airway protection component of swallow. However, bolus efficiency is often the focus of dysphagia assessment and treatment in the DOC population. Bolus efficiency relates to oral acceptance and the anterior to posterior transport of PO bolus and oral secretions. Behavioral and motor response to stimuli and bolus trials within the context of skilled dysphagia therapy should be regularly assessed by a speech-language pathologist in order to determine readiness for modified barium swallow study. This presentation will focus on specific behavioral and motor response observed in the DOC population and the association to swallow function and dysphagia assessment and treatment.
536 Can we agree on what data to collect to characterize the care provided to persons after a brain injury? The neurotrauma care data set
Judy Gargaroa, Olinda Habib Pereza, Laura Langera, Mark Bayleya
aKITE Research Institute, Toronto Rehabilitation Institute -UHN, Toronto, Canada
ABSTRACT
Introduction: Neurotrauma is a leading cause of disability, however, quantifying its impact on society remains difficult due to disconnected databases across the continuum of care and a lack of data measuring long-term care provision and health consequences. Individuals with neurotrauma are frequent users of the health system due to multiple secondary health conditions, often requiring avoidable emergency department visits, and extensive community and social support. Our purpose was to develop an evidence-based, standardized, and prioritized set of data indicators for traumatic brain injury (TBI) that could be applied across the continuum of care and funding mechanisms.
Methods: An environmental scan was conducted to identify data indicators proposed/being collected across different jurisdictions describing a variety of health system, care delivery, and patient-level indicators across the continuum of care for individuals with TBI of all severities. Available published documents and administrative databases pertaining to the current state of care for individuals with brain injury were searched. Key interest partners were convened to develop an evidence-based set of indicators for the Neurotrauma Care Data Set. The partners (n = 95) included people with lived experience, clinicians, researchers, funders, healthcare planners, policymakers and community service providers. Acute, Rehab, and Community Care Working Groups reviewed evidence and identified data indicators, pertaining to their sector of care, necessary to measure key processes in the Ideal Neurotrauma Care Pathway (a companion project). A fourth Working Group focused on Equity Considerations related to social determinants of health, and care planning and provision. Additionally, representatives from marginalized groups, lawyers, and insurers provided feedback on the key elements of care, how best to integrate data indicators collected in the publicly funded system and by third-party providers, and the pressure points for evaluating care.
Results: The search of peer-reviewed manuscripts, reports and data holdings identified 45 organization reports and peer-reviewed manuscripts; 7 for mild TBI and 38 for moderate-to-severe TBI. Virtual summits and two sets (2 X 16) of Working Group meetings were held over 5-month periods to identify gaps in data collection, develop a set of critical data indicators, prioritize a core set of indicators for immediate implementation and develop system-level implementation strategies. Sixty-seven data indicators were identified to create the Neurotrauma Care Data Set. Twenty-two (Core Set) were prioritized for immediate implementation; data were already being collected for 10 and data collection and sharing mechanisms were developed for the remaining 12.
Conclusions: We have brought together a comprehensive group of key partners, importantly including persons with lived experience, funders and government representatives. The Neurotrauma Care Data Set has been developed through consensus to identified key processes within the Ideal Care Pathway. Implementation of these data indicators will provide necessary data to ensure equitable quality evidence-based care across the lifespan after TBI.
537 Move&connect-caregivers: the feasibility of a virtual group-based intervention for caregivers of youth with persistent post-concussion symptoms
Hiba Al-Hakeema,b, Andrea Hicklinga,c, Brendan Lama, Andrew Lovella, Christine Provvidenzaa, Tess Bardikoffa, Carlin Millerb, Shannon Scratcha,d,e
aHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bFaculty of Humanities and Social Sciences, Department of Psychology, University of Windsor, Windsor, Canada, cDepartment of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada, dRehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada, eDepartment of Pediatrics, University of Toronto, Toronto, Canada
ABSTRACT
Background: Youth with persistent post-concussion symptoms (PPCS) experience challenges in physical, social, and emotional domains. Approximately 30% of youth experience PPCS which continue beyond four weeks post-injury, making it difficult for them to return to meaningful activities. Prolonged concussion recovery has also been found to affect caregivers’ mental health and family functioning. Further, parental stress adversely affects the well-being of youth with PPCS. Despite the critical role that caregivers play in youth recovery post-injury, there is no empirically validated intervention tailored to the needs of caregivers of youth with PPCS.
Objective: To explore the feasibility of a virtual, group-based intervention, Move&Connect-Caregivers (M&C-C). PARTICIPANTS: Nine mothers with children between the ages of 13–18 years (M = 15.33, SD = 1.58) participated in the intervention. The average number of concussions sustained was 2.11, with time since recent injury ranging within 5 to 48 months (M = 25.8, SD = 16.31).
Methods: M&C-C is a six-week intervention with weekly one-hour sessions. The intervention was delivered twice: two parent groups with 4–5 mothers per group. The feasibility metrics included recruitment, acceptability, refinement of data collection measures, and resources for intervention implementation. A priori feasibility assumptions were established. Semi-structured exit interviews were also completed after each group, where the interview guide focused on participants’ experience with M&C-C and intervention characteristics.
Analysis: Feasibility metrics were summarized using descriptive statistics. Qualitative content analysis was used to examine interview transcripts.
Results: Findings demonstrate that M&C-C is a feasible intervention for caregivers of youth with PPCS. The metrics collected, including recruitment rate (75%), attendance rate (98%), session adherence (100%), and retention rate (100%), demonstrate that participants were engaged with M&C-C. A visual model was developed to capture the salient features of caregivers’ experience with M&C-C, and included four categories: (1) Caregiver Background, (2) M&C-C Structure, (3) M&C-C Intervention Engagement, and (4) Key Takeaways. Parents’ background reflected a lack of awareness and limited education related to the long-term impact of concussion. M&C-C Structure, which includes design, content, and delivery, promoted a positive and engaging experience for participants. The virtual format of M&C-C was reported to be convenient, accessible, and a safe space to share personal experiences. M&C-C Engagement was reflected with many attributes: camaraderie among caregivers, information sharing, psychoeducation on PPCS, and having a safe space and dedicated time for self-expression. Participants described key takeaways that include the lessons learned, and personal and family insights gained from M&C-C.
Conclusion: Results demonstrate that M&C-C is feasible and meaningful for caregivers. The combined benefits of social support, concussion education, accessibility, and advocacy skills can provide caregivers with the needed support in their youths’ concussion recovery.
540 Traumatic brain injury characteristics predictive of subsequent sleep-wake disturbances in pediatric patients
Brittany Geraldb,c, J. Bryce Ortizb,c, Tabitha Greena, Danielle Brownc, David Adelsonb,c, Sean Murphyb, Rachel Rowea
aUniversity of Colorado Boulder, Boulder, USA, bUniversity of Arizona College of Medicine-Phoenix, Phoenix, USA, cBarrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, USA
ABSTRACT
Traumatic brain injury (TBI) frequently leads to sleep-wake disturbances (SWD) but few studies have characterized TBI-induced SWD in the pediatric population. Here, we sought to determine the prevalence of SWD following pediatric TBI, and to examine characteristics of TBI and patient demographics that might be predictive of subsequent SWD development. We conducted a single-institution, retrospective review of all patients who were diagnosed with a TBI and subsequently diagnosed with a SWD from the years 2008–2019. 207 patients met the inclusion/exclusion criteria and were included in the analyses. Data analyzed included: age at initial TBI, gender, TBI severity, number of TBIs, type of SWD, and time from initial TBI to SWD diagnosis. Multinomial logit and negative-binomial models were fit to investigate if the multiple types of SWD and the time to onset of SWD following TBI could be predicted by patient variables. We found that distributions of SWD diagnosed after TBI were similar between genders. Probability of insomnia increased with increasing patient age. Older TBI patients had shorter time to SWD onset than younger patients. Patients with severe TBI had the shortest time to SWD onset, whereas patients with mild or moderate TBI had comparable times to SWD onset. Multiple TBI characteristics and patient demographics were predictive of a subsequent SWD diagnosis in the pediatric population. This is an important step toward increasing education among providers, parents, and patients about the risk of developing SWD following TBI.
Funding: NINDS R21NS120022, VRP43, Brain Injury Association of America’s Brain Injury Research Fund
541 Differences in emotion recognition between various neurological disorders
Amber Heegersa, S.E. Rakersa, H.J. Westerhof-Eversa,b, L.S. Jornaa, S. Khosdelazada, A.M. Buunka, J.M. Spikmana
aUniversity Medical Center Groningen department neuropsychology, Groningen, Netherlands, bUniversity Medical Center Groningen rehabilitation center location Beatrixoord, Haren, Netherlands
ABSTRACT
Objective: Social cognition disorders can develop after brain damage. Impairments in aspects of social cognition, including emotion recognition, are disorder-transcending and can occur in various neurological disorders such as traumatic brain injury (TBI), stroke (including cerebrovascular accident (CVA) and subarachnoid hemorrhage (SAH)). It is, however, not known if and how patients differ with respect to the extent to which overall emotion recognition as well as recognition of the specific subtypes of emotions (anger, disgust, fear, happiness, sadness, surprise) are impaired. The aim of this study, therefore, is to investigate if and how various neurological patient groups diverge in their pattern of emotion recognition.
Participants and Methods: In this study, patients who suffered from three types of serious neurological disorders were included. Included were: patients with moderate-severe TBI (N = 118; age M = 37.8, SD = 13.7), CVA patients graded 5 or higher on the National Institutes of Health Stroke Scale (NIHSS) (N = 100, age M = 64.9, SD = 10.6) and patients with aneurysmal SAH (N = 121, age M = 54.2, SD = 10.8). Emotion recognition was measured with the The Facial Expression of Emotion-Stimuli and Test (FEEST) in which patients’ ability of recognizing 60 pictures of faces with emotional expressions representing the six basic emotions; (ten of each) was tested. FEEST scores were compared to normative data (median) by means of a One-Sample Wilcoxon Signed Rank Test. Different patient groups were compared on emotion recognition by Independent-Samples Kruskal-Wallis Tests.
Results: Results showed that each patient group scored significantly lower on overall emotion recognition compared to the normative group: all groups (p < 0.001). Moreover, on overall emotion recognition, we found that the TBI group and the CVA group scored significantly lower than the SAH group (p < 0.05) . Furthermore, we found that these neurological disorders significantly differ in recognizing specific emotions. Patients with TBI and patients with CVA scored significantly lower on recognizing sadness than patients with SAH (p < 0.05). Moreover, CVA patients scored significantly lower on recognizing surprise compared to patients with SAH (p < 0.05).
Conclusions: This study shows that impaired emotion recognition is present in various neurological patient groups and is, indeed, disorder-transcending. However, there are differences in severity of impaired emotion recognition between neurological disorders but the pattern between the disorders seems similar. These differences are important to take into account in clinical practice. In this way, patient care and neuropsychological treatments can be more personalized and adapted to patients’ impairments and needs, having a positive influence on treatment outcome.
542 Virtual rehabilitation may improve persisting post-concussive symptoms: a pilot study
Marquise M. Morrisseya,b, James P. Dickeya,b,c, Shannon McGuirec, Becky Moranc, Laura Grahama,b,c
aLawson Health Research Institute, London, Canada, bFaculty of Health Sciences, Western University, London, Canada, cParkwood Institute, London, Canada
ABSTRACT
Introduction: BrainEx90, a combined physiotherapy and occupational therapy outpatient intervention, helps improve symptoms for individuals with persisting symptoms following an mTBI. BrainEx90 was reformatted into a virtual version to deliver care during the COVID-19 pandemic. However, it is unclear whether participants are benefiting from the virtual BrainEx90 intervention.
Objective: The purpose of this study was to determine whether individuals with persisting symptoms following an mTBI would improve their symptoms after completing a virtual version of BrainEx90.
Methods: Participants completed sixteen 90-minute combined physiotherapy and occupational therapy sessions online. All participants completed the Rivermead Post-Concussion Symptom Questionnaire (divided into two sections: RPQ3 and RPQ13), Fatigue Severity Scale (FSS), Generalized Anxiety Disorder 7-Item scale (GAD-7), and Brain Injury Vision Symptom Survey (BIVSS) on their first day of treatment, and again within one week of completing the intervention. Average change in symptom scores were calculated.
Results: This preliminary analysis is based on ten adults (46.2 ± 16.3 years, 6 women) with persistent symptoms following an mTBI (1029.1 ± 529 days since injury), who completed virtual BrainEx90. Average RPQ3 (−2.2 ± 2.3), RPQ13 (−7.6 ± 10.9), FSS (−2.8 ± 13.5), and BIVSS (−3.5 ± 16) scores improved after completing virtual BrainEx90. However, GAD-7 scores worsened (2.2 ± 4.8).
Conclusions: Individuals with an mTBI may experience improved vision, fatigue, and general mTBI symptoms following participation in virtual BrainEx90. However, anxiety symptoms may increase after completing the intervention. These results support need for a larger-scale study to confirm these preliminary trends, and to determine whether virtual platforms or other factors may contribute to increased feelings of anxiety.
543 The development of an interdisciplinary neurotechnology rehabilitation service in a new level 2 specialist neurorehabilitation unit: phase 1
Claire Griffina, Siobhan Kennya, Michelle Fitzgeralda, Mini Mary Paula
aPeamount Healthcare, Newcastle, Ireland
ABSTRACT
Background: A new Level 2 Neurorehabilitation Unit was opened Ireland in 2020 under the National Policy and Strategy for the Provision of Neurorehabilitation Services in Ireland, as the Demonstrator Site for the first Irish Managed Clinical Rehabilitation Network (MCRN). This unit follows an interdisciplinary-team (IDT) rehabilitation model with a strong focus on high quality patient-centered care. Emerging evidence suggests that therapy dosage and intensity provided in neurorehabilitation is currently insufficient (McCabe et al 2015, Schneider et al 2016) and that increases in rehabilitation provision of up to 240% are necessary to optimize recovery in stroke survivors (Schenider et al 2016).
Objective: To explore the feasibility of developing a Neurotechnology Rehabilitation Service as an adjunct to usual rehabilitation, to increase therapy provision in a Level 2 MCRN Demonstrator Neurorehabilitation Unit.
Method: An initial audit and patient experience survey were carried out examining opportunities for rehabilitative activity on the unit, both within and outside therapy working hours. A review of neurotechnology equipment on the market was completed and a database was set-up detailing potential equipment options for the unit. Two ‘GripAble’ upper limb rehabilitation devices were purchased and a pilot was carried out involving patient use of the devices over a 4-week period.
Results: An audit and patient experience survey demonstrated a perceived lack of opportunity for therapy activity amongst patients on the unit, particularly outside therapy time. A database is now in operation detailing potential neurotechnology equipment for the unit, ranging from accessible options suitable for independent patient practice, to advanced rehabilitation technology requiring oversight by therapists trained in their use. A pilot demonstrated that the use of two ‘GripAble’ devices was positively received by patients and staff, although some staff lacked confidence in supporting patients with their use.
Conclusion: The use of neurotechnology as an adjunct to usual rehabilitation is feasible in this MCRN Demonstrator Neurorehabilitation Unit. This project resulted in increased rehabilitation time and in particular allowed increased independent practice of upper limb therapy on the unit. Patients exhibited excellent buy-in for the use of neurotechnology, while gaining additional rehabilitation opportunities through the use of the ‘GripAble’ devices as an adjunct to usual therapy. The next phase of the project will involve a three-pronged approach, including establishment of a ‘Neurotech Hub’ in this organization, purchase of further neurotechnology equipment, and specialist training for therapy staff to develop their skillset in the use of neurotechnology devices as an adjunct to usual rehabilitation. It is anticipated that this Neurotechnology Rehabilitation Service may be rolled out nationally across other Level 2 Neurorehabilitation Units within the MCRN in the future.
544 Sensory processing observation tool – acquired brain injury
Sylvia Taylor-Goha
aRelational Communication Practice Ltd, London, United Kingdom
ABSTRACT
Individuals in a prolonged disorder of consciousness state, after an acquired brain injury are likely to have difficulty communicating, even at the most basic level. They are often reliant on others to observe and accurately interpret their verbal and non-verbal behaviors to enable them to convey their likes, dislikes, and intent. Anecdotal evidence shows that their response to sensory input may be overlooked or misinterpreted which in turn can lead to inappropriate intervention or management.
In response to working with such individuals, the author developed an observational tool, the Sensory Processing Observational Tool (SPOT-ABI) for use by the multidisciplinary team to systematically observe and record an individual’s physiological and behavioral reactions when undertaking a specific activity.
Situated within the neuroscience of sensory processing and modulation, changes to heart rate, oxygen saturation level in addition to a range of other autonomic nervous system and behavioral reactions are obtained. Suggested functional activities encompassing the vestibular, tactile, proprioceptive, auditory, visual, olfactory and gustatory systems are included. Response to functional activities involving vertical, rotary and linear vestibular movements are recorded in addition to discriminative and non-discriminative touch, pressure, vibration, pain and temperature are evaluated within the tactile system as well as passive and active proprioceptive input. Given the behavioral variability inherent for individuals with a prolonged disorder of consciousness, it is essential that observations are repeated over time.
Current use has demonstrated clinical and functional benefits and analysis of the findings has spearheaded change in intervention and day to day management. It is currently being submitted for ethical approval in order that it can widely disseminated in order to gather data during this pilot phase.
545 Brain vital signs with machine learning can classify neurophysiological health across the spectrum of concussion
Shaun Ficklinga,b, Eric D Kirbyb,c, Ryan CN D’Arcya,b,c,d
aNeuroCatch Inc, Healthtech Connex, Metro Vancouver, Canada, bBrainNET, Health and Technology District, Metro Vancouver, Canada, cFacvulty of Applied Sciences, Simon Fraser University, Metro Vancouver, Canada, dDM Center for Brain Health, University of British Columbia, Metro Vancouver, Canada
ABSTRACT
Background: While relatively recent (i.e., within the last 5 years), the concept of “brain vital signs” as a simple and objective neurophysiological evaluation of cognitive function has demonstrated significant clinical utility – particularly in brain injury and concussion. Essentially, the brain vital sign framework translates event-related potentials (ERPs), well-established measures of cognitive processing, into a clinical tool accessible at the point of care. ERPs for auditory sensation (the N100), basic attention (the P300), and cognitive processing (the N400) are stimulated and quantified to provide a rapid evaluation across a spectrum of information processing. Several studies have successfully utilized brain vital signs as the primary measure for quantifying cognitive changes due to acute concussion, monitoring the emergence of subconcussive impairment over the course of a season of contact sports, and evaluating test-retest repeatability in healthy athletes. Here we present a data-driven secondary analysis of the combined results from these studies.
Objectives: The objective of this study was to determine if brain vital sign assessments could classify the likelihood of any given individual to be healthy, concussed, or subconcussed.
Study Design: Secondary analysis
Methods: Brain vital signs data were aggregated from four independent studies in athlete populations (age range 12–21) across multiple sports. This included 33 healthy controls, 61 subconcussed individuals with repeated head-impact exposure, and 15 acute diagnosed concussions (<48 hours post injury), for a total sample size of 109. Principle component analysis was conducted to separate brain vital signs features into linearly separable components. A gradient-boosted decision tree classification model was built using a leave-one-out cross validation method to minimize overfitting and evaluate performance.
Results: Classifying concussion performed the highest (93.44% sensitivity, 91.75% specificity), followed by healthy (81.97% sensitivity, 84.96% specificity), and subconcussion (63.93% sensitivity, 89.92% specificity) for an overall classification accuracy of 79.78%.
Conclusions: Neurophysiological health related to head impact exposure can be evaluated and classified across multiple sports, age-groups, and skill levels. The findings support the concept that objective neurophysiological evaluation of cognitive processing can significantly add to existing clinical assessment and monitoring capabilities in brain injury. This approach has potential to move toward specific diagnostic applications across the spectrum of concussion. Ongoing and future work is focused on expanding this model to include prognostic attributes using groups with longer-term chronic concussion.
546 Communication difficulties and vestibular disorders
Sylvia Taylor-Goha, Sally de la Fontainea, Peter Savundraa, Owen Leigha
aRelational Communication Practice, London, United Kingdom
ABSTRACT
Vestibular difficulties subsequent to an acute or progressive neurological event are not uncommon and the physical consequences are well recognized within the multidisciplinary team. What is less well recognized is the impact upon an individual’s ability to process information, understand verbal information, converse, read and write.
A project was therefore initiated by a multidisciplinary study group, which has representation from 10 different professions involved in brain injury rehabilitation, in order to explore the incidence and prevalence of communication difficulties for those with vestibular disorders post acquired brain injury.
It is important to delineate within this data gathering exercise those individuals who have an existing communication disorder diagnosis, such as cognitive-communication disorder or aphasia and those for whom communication is affected in the absence of a communication diagnosis. Clearly, the difference will impact potential intervention and management.
It is anticipated that the findings from the project will be disseminated to professional groups and organizations involved in the commissioning of services and providing advice.
In order to capture data, it was agreed that an online anonymized survey would be an appropriate method of data collection. To that end, the lead author developed a 13 question survey which was reviewed and refined by the multidisciplinary team study group. It takes around 15 minutes to complete.
The survey is designed featuring a variety of question types, including multiple-choice, ranking and open-ended. Questions address medical history and presenting symptoms, current speech and language therapy input, if any, understanding spoken information, talking, reading, writing, impact of difficulties and ways of managing difficulties.
The survey has been piloted by individuals known to members of the study group in order to review the reliability and validity of the survey design and content. The preliminary data has been analyzed and it is evident that everyday communication difficulties are experienced by those with vestibular disorders, even in the absence of a defined communication disorder. The survey is currently being submitted for ethical approval in order that it can widely disseminated for the main data collection phase and the findings analyzed and with the potential to inform clinical practice.
547 Routinely collected clinical data sets collected using a novel electronic patient assessment system enable mapping of services and patient profiles
Penny Traynera,c, Simon Kellyc,d, Andrew Batemanb
aClinical Neuropsychology Services Ltd., Manchester, United Kingdom, bUniversity of Essex, Colchester, United Kingdom, cGoal Manager, Manchester, United Kingdom, dSunniside Software Ltd., Warrington, United Kingdom
ABSTRACT
The objective of this analysis was to explore the potential of a new platform used by a diverse range of non-NHS (private and not-for-profit) organizations in the UK and USA to shed light on how these services assess brain injury survivors and the diversity of problems found in routine clinical practice.
Goal Manager® is a novel digital platform supporting assessment and goal setting in rehabilitation. The assessment platform is built around the core datasets of the WHO ICF. Clinicians are able to quickly populate a comprehensive assessment using easy to navigate drop-down boxes and this ensures the ability to standardize assessments between different patients and services. Using a common data set maximizes the use of the data for analysis.
Anonymous data from ICF assessments are automatically sorted and collated by Goal Manager and then extracted for analysis, allowing for quick and easy consideration of this routinely collected clinical data.
Data pertaining to patients seen between January 2019 and September 2022 were anonymized and extracted. Frequencies of ICF codes and environmental factors (facilitators and barriers) were compiled.
Results: We reviewed 98 Traumatic Brain Injury Comprehensive, and 12 Brief, ICF core sets completed by community services.
The top 10 codes identified within these assessments were:
ICF Code – ICF Category
b152 – Emotional functions
d240 – Sensations associated with hearing and vestibular function
b130 – Energy and drive functions
b140 – Attention functions
b164 – Higher-level cognitive functions
d230 – Carrying out daily routine
d177 – Making decisions
b160 – Thought functions
d330 – Speaking
b144 – Memory functions
The diversity of other codes utilized emphasizes the heterogeneity of problems experienced by people living with brain injury.
Within the ICF section facilitators or barriers;
The top 5 facilitators identified were:
ICF Code – ICF Category
e355 – Health professionals
e360 – Other professionals
e450 – Individual attitudes of health professionals
e340 – Personal care providers and personal assistants
e310 – Products and technology for communication
The top 5 barriers identified were:
ICF Code – ICF Category
e410 – Individual attitudes of immediate family members
e310 – Immediate family
e155 – Design, construction and building products and technology of buildings for private use
e330 – People in positions of authority
e115 – Products and technology for personal use in daily living
Conclusion: These provisional findings are discussion in the context of tentative hypotheses about service users’ needs which will continue to be explored and refined using Goal Manager’s growing database.
Future work will involve feedback to individual services about how they are using the platform and to develop an understanding to barriers to completing comprehensive best practice assessments.
Based on this provisional work, we are developing a research and evaluation dashboard to facilitate continuing improvement and easy access to clinical research data for services in order to further the understanding of brain injury rehabilitation and recovery.
548 Protocol of speech and language outcomes and their neural correlates following childhood stroke
Christine Muscata,b,c, Angela Morganc,d,e, Shannon Scratcha,b, Deryk Beala,b
aUniversity Of Toronto, Toronto, Canada, bBloorview Research Institute, Toronto, Canada, cUniversity of Melbourne, Victoria, Australia, dMurdoch Children’s Research Institute, Victoria, Australia, eRoyal Children’s Hospital, Victoria, Australia
ABSTRACT
Background: Pediatric stroke is a neurological injury caused by the occlusion or rupture of cerebral blood vessels and can be classified as perinatal (< 28 days) or childhood stroke (28 days to 18 years). A staggering 41 to 75% of children demonstrate impairments in speech and language functioning following stroke. A crucial stage for speech and language recovery is the subacute rehabilitative stage, which occurs approximately 3 to 11 weeks following stroke onset. Despite the importance of this stage, there is little research describing speech and language outcomes during the course of rehabilitation, as well as the underlying neural mechanisms that are associated with speech and language impairments.
Objectives: We aimed to: (1) prospectively document the feasibility in obtaining clinical speech and language outcomes and their neural correlates throughout the subacute phase of recovery during an intensive rehabilitation program and (2) develop an assessment protocol to investigate neural correlates of speech and language outcomes following stroke.
Feasibility: To explore study and recruitment feasibility, inpatient childhood stoke census data were analyzed from the Brain Injury Rehabilitation Team (BIRT) at Holland Bloorview Kids Rehabilitation Hospital in Toronto, Canada. From January to September 2022, 161 clients (ages 8 months to 18 years; 61 females and 98 males) were admitted to the BIRT program. Of the 161 clients admitted with an acquired brain injury (e.g., TBI, seizures, hydrocephalus, brain tumor) 21 clients were admitted due to a childhood stroke diagnosis. Sixteen of the 21 clients met eligibility criteria for this study; five did not meet inclusion criteria due to age, stroke secondary to trauma, and premorbid neuropsychological diagnoses. Since the start of study recruitment in September 2022, one of two eligible clients have successfully enrolled in the clinical assessment portion of the study.
Protocol: The study protocol was then developed whereby children (3–18 years) will complete clinical speech and language assessments and a magnetic resonance imaging (structural, functional) scan at three time points: admission, discharge, and 3 months post-discharge. A similar protocol with children post-stroke will be followed at the Royal Children’s Hospital in Melbourne, Australia.
Implications: Leveraging clinical data from assessment practices at Holland Bloorview in addition to obtaining neuroimaging data, will assist in better understanding of speech and language outcomes and their neural correlates following childhood stroke across rehabilitation (admission, discharge) and recovery (3-months post-discharge).
549 Exploring the feasibility of the youth concussion awareness network (You-CAN): a peer-led concussion education program for Canadian high school students
Brynna Kerra, Katherine Wilsonb, Christina Ippolitob, Kylie Mallorya,c, Emily Kroshusd,e, Michael Hutchisonf,g, Nick Reeda,b,c
aRehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, bDepartment of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, cBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, dCenter for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, USA, eDepartment of Pediatrics, University of Washington, Seattle, USA, fFaculty of Kinesiology & Physical Education, University of Toronto, Toronto, Canada, gKeenan Research Center of the Li Ka Shing Knowledge Institute at St. Michael’s Hospital, Toronto, Canada
ABSTRACT
Background: Concussions are a prevalent injury amongst youth in Canada, yet there remains a lack of concussion education provided to youth. Concussion education can equip youth with the knowledge and skills needed to recognize and report a concussion. To date, there is a lack of understanding around best practices for concussion education in the school environment, as most educational interventions targeting youth have been directed to the sport community. Moreover, concussion education has been regularly designed and delivered by adults rather than youth and thus may not meet youths’ wants and needs.
Methods: This study aims to explore the feasibility of the Youth Concussion Awareness Network (You-CAN), a peer-led concussion education program for high school students. Four Canadian high schools from three provinces participated in the study. Participating schools (P1-P4) were invited to complete the You-CAN program, which required schools to: (1) create a student concussion council; (2) deliver a student-led concussion awareness campaign in their school using provided evidence-based resources; and (3) share the impact of their campaign in a showcase with other participating schools. Program feasibility was evaluated through an analysis of program retention, adherence, and effectiveness. Retention and adherence were assessed using the materials submitted by schools to the research team. Effectiveness was assessed using a school-wide survey (n = 35 paired) based on the Theory of Planned Behavior delivered before and after the program to measure changes in concussion knowledge, along with intended concussion reporting and social support behaviors. Survey data was analyzed using descriptive statistics.
Results: In terms of program retention, three schools (P2, P3, P4) completed their campaigns. Program adherence varied; one school (P4) used external resources to inform their campaign and another school (P3) did not participate in the showcase. Campaigns had varying effectiveness on changing concussion knowledge and intended concussion reporting and social support behaviors. The mean knowledge score for two of four schools increased following participation in the study (P1 Pre: M = 8.75, Post: M = 11.25; P4 Pre: M = 9.38, Post: M = 10.19). After exposure to their school’s campaign, two schools showed a positive percent change in responses related to students’ confidence in their ability to report a suspected concussion (P2: +2.6%, P3: +5.6%). Additionally, two schools saw a positive percent change in responses related to students’ beliefs about social norms associated with providing support to a peer with a concussion (P2: +5.6%, P4: +10.2%).
Conclusions: You-CAN utilizes a peer-to-peer education model to enable youth to teach each other about concussions and promote positive concussion behaviors. Findings suggest that You-CAN is feasible. Further studies are warranted to improve program adherence and evaluate the effectiveness of You-CAN. Study findings may help inform the design and implementation of youth-driven concussion education programs.
550 Keeping the person at the center of a virtual world: transformation of community brain injury rehabilitation
Alison Keysa, Romayne Orra, Jill Holden-Downesa
aSouth Eastern Health and Social Care Trust, Newtownards, United Kingdom
ABSTRACT
Background: The Covid-19 pandemic created unprecedented challenges for healthcare systems, leaving some of our most vulnerable clients without access to services. Covid 19 presented an opportunity to reflect on current service delivery and look at new ways of working. Self-management is a key component of person centered care and a priority for commissioners. Evidence shows this approach can result in improved quality of life and improved clinical outcomes for service users as well as improved use of healthcare resources (De Silva et al. 2011).
Objectives: Digital technology offered a potential solution to the continued delivery of brain injury rehabilitation at the beginning of the pandemic. By utlising digital resources the service wanted to ensure that intervention remained person centered, individualized, therapeutic and equitable. The MDT recognized it remained essential that service users were still supported in achieving what is most important to them, building knowledge skills and confidence to live their lives to the full post injury. QI methodology was used to measure progress and clinical outcomes.
Method: Occupational Therapy and Speech and Language Therapy piloted a co-produced and co-delivered virtual group intervention focusing on self-management. This was evaluated with the use of questionnaires and virtual interviews with service users, carers, and members of the MDT. Evaluation highlighted one size doesn’t fit all and the need to tailor interventions to meet a complex range of clinical need whilst ensuring digital access for all service users particularly those with moderate to severe difficulties. Based on feedback received, further virtual personalized individual and group interventions addressing issues of fatigue, memory and communication difficulties post-brain injury were developed.
Results: Community brain injury rehabilitation was delivered and maintained throughout the pandemic. This resulted in no waiting lists for intervention and service users having rapid access to specialist support. Having service users and carers attend sessions together guaranteed access to intervention for all. Functional outcome measurements (Mayoportland) showed an improvement post treatment for all service users. Additionally, quality of life measurements (QOLIBRI) showed an increase pre and post treatment for all service users. By co-producing and co-delivering a menu of virtual interventions team members realized that service users and carers were valuable hidden resources rather than drains on the service. Continuing to deliver part of the service virtually has increased clinical capacity by 66% due to reduced need for travel for all interventions. Since April 2020, 2180 virtual treatment sessions have been delivered. Working this way has saved approximately £478,282.
Conclusion: This model of rehabilitation proved to be efficient and productive, providing a broad choice of intervention to service users. This blended method of service delivery is suitable for scale and spread amongst similar services.
552 Non-pharmacological Supplements as a Potential Neuroprotective Intervention for Subconcussive Impairment
Shaun Ficklinga,b, Logan Breuerc,d, Tory Frizzella,b, David Dodicke,f, Aynsley Smithc,d, Ryan D’Arcya,b,g, Michael Stuartc
aNeuroCatch Inc, Healthtech Connex, Vancouver, Canada, bBrainNET, Health and Technology District, Metro Vancouver, Canada, cDepartment of Orthopedic Surgery, Sports Medicine Center, Mayo Clinic, Rochester, USA, dDepartment of Physical Medicine and Rehabilitation, Sports Medicine Center, Mayo Clinic, Rochester, USA, eDepartment of Neurology, Mayo Clinic, Phoenix, USA, fAtria, New York City, USA, gDM Center for Brain Health, University of British Columbia, Metro Vancouver, Canada
ABSTRACT
Background: Exposure to repetitive head impacts is a routine aspect of contact sports. There is increasing evidence indicating that these events, even orders of magnitude below the detectable threshold for a diagnosed concussion, can accumulate over time to change brain structures and associated functions. Studies have also linked head impact exposure to longer term neurodegenerative disorders such as chronic traumatic encephalopathy and traumatic encephalopathy syndrome. Point-of-care neurophysiological technologies that evaluate electroencephalography, saccadic eye movement, and blood biomarkers are promising objective tools to measure these subtle subconcussive changes. These technologies have shown robust and repeatable results in detecting subconcussive changes and, importantly, quantifying these changes in terms of head-impact exposure. Objective measurement tools are also helpful to evaluate interventions. Indeed, there are a range of potential non-pharmacological approaches for proactive treatment, many of which have been researched in relation to the pathophysiology of acute concussion such as magnesium, resveratrol, glutathione, circumin, docosahexaenoic acid, and branched-chain amino acids.
Objectives: The objective of this study was to determine if the use non-pharmacological supplements have a neuroprotective effect when compared to placebo.
Study Design: Double-blind placebo/control
Methods: Participants (n = 30, age 17–21) from two Junior-A Ice Hockey teams were recruited to participate in this study. Half (n = 15) received a dietary supplement as an intervention, and half (n = 15) received a placebo. Both intervention and placebo doses were dissolved in water and ingested twice per day for the duration of the hockey season. All players were evaluated at preseason and postseason using a battery of cognitive tests including brain vital signs from the NeuroCatch rapid event related potential platform, the King-Devick test of saccadic eye movement, Neurofilament Light polypeptide blood biomarkers, and SCAT-5, Neuro-QOLSFv2, and PHQ-4 questionnaires. Statistical analysis included a multivariate, repeated measures, general linear model with covariates for prior concussion history and number of games played as a proxy for head impact exposure.
Results: A significant multivariate Group*Time effect was observed (p < 0.05) identifying differential changes in the placebo and intervention groups over the course of the season. This included significant univariate differences between groups in NeuroCatch N100 latency (p < 0.01) and King-Devick score (p < 0.05), with trends for differences in Neurofilament Light (p = 0.059) and NeuroCatch N400 amplitude (p = 0.095). Players with a history of prior concussions showed additional significant changes in NeuroCatch N100 latency (p < 0.05), N400 latency (p < 0.01), and Neurofilament Light (p < 0.05).
Conclusion: The use of non-pharmacological supplements during a season of contact sport resulted in less subconcussive neurological changes based on objective neurophysiological assessments. These supplements may provide critical nutrients and energy substrates to balance disrupted homeostatic processes and therefore could be a potential prophylactic intervention for subconcussion. A benefit to dietary supplements is that they are safe, inexpensive, accessible, and can be taken regularly.
553 From medical model to empowerment theory: no place like home, the Kansas experience
Janet Williamsa, Erica Batesb
aCommunityworks Inc., Overland Park, USA, bMinds Matter LLC, Overland Park, USA
ABSTRACT
The use of rehabilitation therapies for people with brain injuries has traditionally occurred within an inpatient setting or outpatient clinic. When provided at home the therapy is often limited to short visits and for a short duration of several months. In the United States that occurs because it is what insurance funds and the area that receives the most attention and research. For the past 30 years there has been a revolution happening in Kansas, in the middle of the United States, where people go to their own home from rehabilitation and receive intensive rehabilitation for an average of two years by therapists with knowledge of and extensive training in brain injury. They can also receive attendant care, equipment and home modifications paid for by our federally/ state funded insurance system, Medicaid.
The shift to receive rehabilitation at home has co occurred with a shift from professionals determining rehabilitation goals to the person determining their own goals. This shift from the medical model of fixing people to an empowerment model has resulted in people making decisions congruent with what they truly prefer. Some positive results of using empowerment theory include improved active participation, coping with illness, increased assertiveness and acceptance of disability. Adding a rehabilitation component to empowerment theory results in therapists being able to facilitate and maximize opportunities for people to have control over their environment and function as independently as possible in the normal rhythms of the day.
This brings us to an important question: How do people shift from the medical model to the empowerment model? This presentation will outline theoretical concepts of both the medical model and the empowerment model. In addition, we will provide outcome data from two tools, the Behavior Rating Inventory of Executive Function- Adults (BRIEF A) and the Mayo Portland Adaptability Inventory (MPAI-4). This will be followed by two case studies that demonstrate the utilization and effectiveness of this model. We will also include a comparison of costs and outcomes between a residential model of rehabilitation and an in home and community-based model.
554 Understanding parallels and peculiarities: a protocol for a multi-site pilot study on persistent concussion, anxiety, neuropsychology, and neuroimaging (PeCANN)
Elena Sheldrakea,b, Anne Wheelerc,d, Benjamin Goldsteine,f,g, Benjamin Dunkleyc,h, Matthew Burkeg,i, Nick Reedb, Shannon Scratcha,b,j
aBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, cNeuroscience and Mental Health Program, The Hospital for Sick Children, Toronto, Canada, dDepartment of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, eThe Center for Addiction and Mental Health, Toronto, Canada, fDepartment of Pharmacology & Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, gDepartment of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, hInstitute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, iSunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Canada, jDepartment of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
ABSTRACT
Background: Concussions are increasing each year. Children and youth are at greater risk of concussive injury and prolonged recovery due to their developing brain. While most youth recover within four weeks, approximately 30% experience persistent post-concussion symptoms (PPCS), lasting months to years. Youth with PPCS often experience mental health concerns such as anxiety and depression. However, it is challenging to predict which youth are more likely to experience PPCS and require interdisciplinary support, as clinicians rely on self-report and patient history for diagnosis. Additionally, there are no consistently observed structural neuroimaging biomarkers to detect and predict outcome following concussion. The usage of MRI multi-modal imaging is an avenue that shows potential to detect objective neuroimaging markers in concussion.
Objective: The PeCANN study is a pilot project targeted at identifying differences and similarities in functional neuroimaging and neuropsychological outcomes between youth with PPCS (study group) and youth with anxiety (control group), to better understand the long-term emotional outcomes of pediatric concussion. Given the significant anxiety symptoms experienced by many youths with PPCS, the inclusion of an anxiety control group (without a history of concussion) provides a unique comparison targeting mental health concerns.
Participants: Two groups aged 12–18 years (PPCS and age- and sex-matched anxiety controls; n = 25 per arm). Youth with PPCS are recruited from Holland Bloorview’s Persistent Concussion Clinic, the only publicly funded clinic of its kind in Canada. To date, 13 youth have completed the study (nine PPCS, five anxiety), with recruitment ongoing.
Procedure: Participants in both groups will undergo the following: (1) Neuropsychological assessment with emphasis on anxiety, mood, and cognition, and (2) MRI to compare structural neuroanatomical and functional connectivity differences between groups. Neuropsychological assessment is comprised of a comprehensive battery testing cognitive domains (general intelligence, attention, memory, executive function) using standardized clinical measures. Self-report and parental questionnaires on emotional and behavioral outcomes are also completed. Multi-modal 3T MRI utilizes structural modalities, such as T1- and T2-weighted imaging for image acquisition, perfusion weighted imaging, and diffusion weighted imaging, as well as functional MRI to capture a comprehensive overview of brain properties.
Analysis: Data analysis will entail multivariate, logistic regression pipelines to compare neuroimaging data to neuropsychological assessment results. Variables assessed will include but are not limited to age, sex, medications, and socioeconomic status.
Implications: Project outcomes will foster discussions by targeting youth at greatest risk for psychological morbidity post-concussion. Investigating the connections of emotional outcomes and neuroimaging in the two groups with similar clinical presentations will clarify ambiguities between PPCS and mental health symptom interconnection. By examining the underlying pathophysiology of PPCS, this research aims to identify neural targets for therapeutic interventions such as brain stimulation, which will enhance the diagnosis and management of chronic concussion symptoms.
555 Assessing the impact of residential neurorehabilitation prior to transition to the community on outcomes for acquired brain injury survivors accessing services within acquired brain injury ireland (protocol)
Ellen Conlona
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland
ABSTRACT
Background: It is estimated that 120,000 people in Ireland live with disabilities as a result of an acquired brain injury (ABI). Due to the diverse nature of ABI consequences, optimal neurorehabilitation strategies vary from individual to individual. Research shows there is no consistent pathway of care in place for ABI survivors in Ireland. ABI survivors with earlier access to neurorehabilitation services have better outcomes than those who access services later. The lack of a pathway of care, and delays accessing neurorehabilitation services can therefore result in “lost potential” for recovery. Since 2000, Acquired Brain Injury Ireland have delivered neurorehabilitation in both residential and community settings to ABI survivors in Ireland. While many clients begin service within the community, since 2000 more than 60 clients have spent time in Acquired Brain Injury Ireland residential services before transitioning to the community, where they have continued to access neurorehabilitation. To assess effectiveness of service, since 2018, Acquired Brain Injury Ireland collect quarterly outcome data using the Mayo-Portland Adaptability Inventory-4 (MPAI-4) in both residential and community settings. To date, it has not been formally investigated whether a period of residential neurorehabilitation has an impact on the outcomes experienced once clients transition to the community.
Aim: To assess whether a period of residential neurorehabilitation affects outcomes after transition to the community, compared to clients who begin service in the community. Secondary aim is to assess the cost of providing each service, to determine whether there is value in investing in transitional models of care within Acquired Brain Injury Ireland.
Methods: Clients will be identified using internal records. All identified clients will be analyzed using descriptive statistics. Clients in service since 2018 will be included in analyses of MPAI-4 data. Clients will be matched with comparators who have not received residential services. Cost of respective services will be calculated with assistance from finance department and records of hours allocated to individual clients during time in service, where available. All data will be anonymized as per service agreements with clients.
Results & Discussion: It is hoped that the findings of this investigation can inform service development within Acquired Brain Injury Ireland. As an organization dependent on government funding and public fundraising, it is crucial to attain evidence to guide and support best use of funds while maintaining optimal service provision and outcomes for clients. Evidence that favors a transitional model of care could be used to advocate for expansion of short-term residential neurorehabilitation spaces in Ireland. A transitional model of care could be an alternative to nursing home placement following acute treatment post ABI. This may also be suitable for ABI survivors without appropriate housing or familial support to allow them to access neurorehabilitation within community settings.
556 Identifying gaps in return to play: a qualitative study of clinician perspectives of a multidomain assessment for youth with concussion
Josh Shorea,b, Danielle DuPlessisa,b, Emily Lama, Hiba Al-Hakeema, Virginia Wrighta,b,c, Nick Reeda,b,d, Elaine Biddissa,b,e, Shannon Scratcha,b
aBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute, University of Toronto, Toronto, Canada, cDepartment of Physical Therapy, University of Toronto, Toronto, Canada, dDepartment of Occupational Sciences and Occupational Therapy, University of Toronto, Toronto, Canada, eInstitute of Biomedical Engineering, University of Toronto, Toronto, Canada
ABSTRACT
Background: Traditional return-to-play (RtoP) protocols after concussion rely on a battery of single-domain assessments (e.g., standing balance, running on treadmill) and self-reporting of symptoms to determine injury resolution. However, single-domain assessments may fail to detect symptoms or performance impairments that are elicited by the combined physical, cognitive, and emotional demands of sport, thus putting athletes at risk for re-injury. Our team sought to address this gap by creating the R2Play system, a technology-mediated multidomain RtoP assessment for youth with concussion. The R2Play assessment combines physical, cognitive, and sensory domains. It consists of a series of tablet “buttons” displaying numbers and letters that youth must run between and connect in ascending alphanumerical order (i.e., 1-A-2-B …). Performance is measured via time to completion, dual-task costs, and error scores across several trials of increasing difficulty.
Objective: A key step in the R2Play development process was to conduct qualitative interviews with front-line clinicians to explore: (1) current methods of RtoP assessment; and (2) how the R2Play system should be designed to best meet the needs of clinician end-users.
Methods: Clinicians with at least one year experience working in pediatric concussion were recruited from concussion clinics (internal and external to our hospital). Semi-structured interviews were conducted online using the Zoom videoconferencing platform. Interviews involved general discussion of clinicians’ RtoP assessment experiences, demonstration of the early R2Play prototype, and targeted feedback on the assessment concept. Interviews were audio recorded, transcribed verbatim, and analyzed using conventional content analysis.
Results: Six clinicians from various rehabilitation disciplines completed interviews. Clinicians reported a variety of approaches to evaluating readiness for RtoP, which relied heavily on clinical experience given a lack of standardized objective assessment protocols. Clinicians commented on the perceived utility of R2Play as a comprehensive assessment, while emphasizing the need for further system development and standardized scoring. Feedback was generally positioned within three topics: (1) the individuals being assessed; (2) the R2Play system; and (3) the testing environment. Refinements to the R2Play system itself were further sub-divided to those related to the task, hardware, interface, scoring, and training. Clinicians also described a need for novel rehabilitation tools to help simulate realistic sport environments that integrate physical and cognitive demands in a clinical setting.
Conclusions: This research contributed to the development of the R2Play system, a new multidomain assessment designed to support safe return-to-sport for youth with concussion. It also helped identify important gaps in the current post-concussion return-to-sport process to inform future research.
557 Investigating connections between concussion and mental health using the adolescent brain cognitive development retrospective data
Ms. Elena Sheldrakea,b, Anne Wheelerc,d, Benjamin Goldsteine,f,g, Nick Reedb, Shannon Scratcha,b,h
aHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, cNeuroscience and Mental Health Program, The Hospital for Sick Children, Toronto, Canada, dDepartment of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, eThe Center for Addiction and Mental Health, Toronto, Canada, fDepartment of Pharmacology & Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, gDepartment of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, hDepartment of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
ABSTRACT
Background: Concussion is a heterogenous injury where symptoms include physical, cognitive, behavioral/emotional, and sleep-related concerns. Youth with concussion often report lower quality of life outcomes. For example, studies report significant changes to mental health following concussion, as onset of anxiety symptoms or exacerbation of existing anxiety symptoms seem to be a common occurrence after injury. While there is a bidirectional link between concussion and mental health, the causation remains unknown. The Adolescent Brain Cognitive Development (ABCD) study is a prospective, longitudinal study, following youth participants for 10 years, beginning at the age of 9–10 years old (n = approx. 12,000). This study measures a variety of factors, including brain development, emotional and cognitive development, mental health, and gender identity using both self-report and parental measures.
Objective: This project aims to identify differences and similarities in functional neuroimaging and neuropsychological outcomes between youth with concussion, in comparison to youth with anxiety and typically developing youth, to better understand the distinctions and interconnections between health outcomes in youth experiencing these conditions.
Methods: Using retrospective data from the ABCD study, the following outcomes will be investigated: (1) behavioral and emotional profiles characterized by parent questionnaire (Child Behavioral Checklist (CBCL)), and (2) neural underpinnings using diffusion tensor imaging (DTI).
Participants: The study group, youth with reported concussion, were identified using the Ohio State University TBI Identification Method. Youth who reported having a brain injury with loss of consciousness ≤ 30 minutes and/or loss of memory were included (n = 178). Two control groups are used: (1) Youth with reported anxiety symptoms (generalized and/or social), as identified using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (n = 166), and; (2) age- and sex-matched healthy controls (n = 178).
Results: Retrospective data was extracted from the 2-year follow-up time frame; therefore, youth were approximately 12 years-old at time of data collection. Youth with concussion are predominantly male (68%) and Caucasian (73%). Statistical analysis is underway (estimated results by December 2022), and will include multinomial logistic regression modeling to predict the probability that specific group type (concussion group, anxiety group, and healthy control) relates to internalizing or externalizing syndrome scale score on CBCL. DTI metrics will utilize tractography measures, by using whole-brain analysis to display differences in white matter pathways between the study group and control groups, in localized/distinct or broad regions. Logistic regression modeling will also be used to understand if CBCL scores relate to DTI metrics of youth with concussion. Covariates of interest include: sex, race, pubertal status, socioeconomic status, and parent marital status.
Conclusion: Results will augment understanding surrounding concussion and mental health ambiguity, by highlighting emotional symptom and potential relation to neuroimaging biomarkers.
558 Harmonizing lifetime traumatic brain injury (TBI) screening tools across longitudinal cohort studies
Nicola de Souzaa, Ashlyn Bulasa, Raj Kumara, Lisa Spielmana, Jesse Mezb, Kristen Dams-O’Connora
aIcahn School of Medicine At Mount Sinai, New York, USA, bBoston University, Boston, USA
ABSTRACT
Traumatic Brain Injury (TBI) is an established risk factor for accelerated decline in later-life including dementia, but the strength of association varies widely across studies. Previous studies of cognitive aging and dementia are limited by inconsistent definitions of TBI exposure, limited TBI ascertainment methods, and small sample sizes. A strategy to overcome these limitations is to pool existing data from studies that use gold-standard self-report TBI measures, but this requires item-level harmonization of disparate screening methods. The Brain Injury Screening Questionnaire (BISQ) and the Ohio State University Traumatic Brain Injury Identification Method (OSU-TBI-ID) are recognized by the National Institutes of Health (NIH) as Common Data Elements (CDEs) for TBI. As such, the purpose of this study was to develop a harmonization protocol to pool BISQ and OSU-TBI-ID data. Data were collected across five ongoing longitudinal cohort studies, the Adult Changes in Thought study (ACT, n = 587), Memory and Aging Project (MAP, n = 2196), Religious Orders Study (ROS, n = 1485), Minority Aging Research Study (MARS, n = 779), and Framingham Heart Study (FHS, n = 16013). The BISQ was used in ACT, MAP, ROS, and MARS, and the OSU-TBI-ID was used in FHS. The abbreviated BISQ has 7 core items and additional queries pertaining to repetitive head impacts (RHI) in contact sports, military service, and intimate partner violence; the OSU-TBI-ID has 5 core items and an open-ended query regarding RHI. Both tools use skip logic such that those who endorse an injury to the head/neck in a given context are asked to report duration of unconsciousness or altered consciousness. We reviewed the administration, scoring, and coding procedures across sites, evaluating more than 100 screening items. We then evaluated open-text responses for injury etiologies not cued by the primary tools, and classified them according to closest-fit etiological categories. More detailed contextual cues and duration of unconsciousness/altered consciousness data from the BISQ were collapsed into categories provided on the OSU-TBI-ID. Data were then mapped to the Department of Defense/Centers for Disease Control and Prevention schema for TBI severity classification. In each of the five studies, we created 15 calculated variables to characterize TBI severity, loss of consciousness duration, post-traumatic amnesia duration, most severe TBI, most recent TBI, and number of lifetime TBIs. For RHI, we created dichotomous (present/absent) and continuous (duration of exposure) variables. The overall result is a feasible and systematic approach for harmonizing lifetime TBI exposure data from two commonly used tools. This work is foundational to ongoing international efforts to retrospectively and prospectively harmonize data across studies to accelerate knowledge of post-traumatic neurodegeneration, and will enable robust, highly powered investigation of TBI as a risk factor for dementia.
559 Characterizing lifetime trauma exposure in female survivors of intimate partner violence (IPV) and traumatic brain injury (TBI)
Nicola de Souzaa, Ariel Pruysera, Emily Blunta, Christine Mac Donaldb, Jeanne Hoffmanb, Yelena Bodienc, Brian Edlowc, Kristen Dams-O’Connora
aIcahn School Of Medicine At Mount Sinai, New York, USA, bUniversity of Washington, Seattle, USA, cMassachusetts General Hospital, Boston, USA
ABSTRACT
Background: Intimate partner violence (IPV) confers a high risk of traumatic brain injury (TBI), particularly among women, due to frequent and repetitive physical violence directed at the face, head, and neck. Evidence suggests that the combination of psychological and neurological trauma may contribute to worse psychiatric outcomes, such as higher rates of post-traumatic stress disorder (PTSD), anxiety, and depression. IPV is also associated with earlier life trauma and exposure to violence. However, the association between IPV and early life trauma has not been examined in individuals with TBI. In addition, it is unknown how traumatic experiences across the lifespan may independently and cumulatively affect psychological outcomes following TBI.
Objective: To characterize exposure to lifetime trauma in females with and without IPV exposure, and to examine whether cumulative lifetime trauma exposure predicts worse psychological outcomes following TBI. METHODS: Data were collected from female participants (n = 73; age: mean [M] = 50.5, standard deviation [SD] = 15.4) enrolled in the Late Effects of TBI (LETBI) study after sustaining a complicated mild to severe TBI (time since injury: M = 12.6 years, SD = 10.4). All participants completed the Brain Injury Screening Questionnaire (BISQ), a structured assessment of lifetime history of TBI, including an additional IPV module to characterize blows to the head from physical violence by an intimate partner. Lifetime trauma exposure was assessed with the Adverse Childhood Experience (ACE) Questionnaire and the Survey of Exposure to Community Violence (SECV). Psychological functioning was assessed with the Primary Care PTSD Screen for DSM-5 and Quality of Life in Neurological Disorders (Neuro-QOL) Anxiety and Depression scales. We compared lifetime trauma exposure and psychological outcomes between those with and without IPV. Multivariate regression models also examined the association between childhood trauma, exposure to violence, and IPV with psychological functioning.
Results: Among females with TBI, those with IPV reported significantly elevated exposure to ACEs (IPV: M = 4.3, SD = 2.9; No IPV: M = 1.6, SD = 1.8; p = 0.004) and SECV (IPV: M = 17.7, SD = 8.5; No IPV: M = 7.7, SD = 6.1; p < 0.001) as well as more severe symptoms of PTSD (IPV: M = 2.8, SD = 1.7; No IPV: M = 0.9, SD = 1.4; p < 0.001). There were no group differences in depression or anxiety scores. When controlling for the number of lifetime TBIs, ACEs (p = 0.04) and SECV (p = 0.02) significantly predicted worse PTSD (F [4, 67] = 11.23, p < 0.001), and SECV (p = 0.045) predicted worse anxiety (F [4, 69] = 3.90, p = 0.007).
Conclusions: The findings suggest that lifetime exposure to trauma has important implications for psychological outcomes following TBI and may be particularly relevant for those with IPV and IPV-related TBI. TBI survivors with a history of cumulative lifetime trauma may benefit from trauma-informed treatment approaches.
560 “It’s not one person’s responsibility, it’s everybody’s responsibility, which often means that it’s no one’s responsibility.” Sexuality and acquired brain injury: a qualitative exploration of the attitudes and approaches of australian health professionals in addressing sexuality
Jill Hwanga, Elinor Frasera, Marina Downinga, Jennie Ponsforda
aMonash University, Clayton, Australia
ABSTRACT
Background and Aims: Acquired brain injury (ABI) through events, such as stroke or trauma, is a leading cause of disability in Australia. Studies indicate that up to 50% of survivors of ABI suffer persistent and multi-faceted changes in sexuality that can stem from the physiological, neurological, and psychological consequences of ABI. However, research on health professionals’ perspectives in addressing sexuality issues post-ABI is limited. This study explored the attitudes and approaches, barriers and facilitators, and training preferences of Australian health professionals in addressing sexuality in individuals post-ABI.
Methods: Purposive sampling was used to recruit 20 Australian multi-disciplinary health professionals from a related survey study. Semi-structured interviews were conducted and qualitatively analyzed using thematic analysis.
Results: Three broad themes were identified. First, health professionals have a good understanding of how consequences of ABI can result in multi-faceted changes in sexuality. Second, there is a fundamental discomfort in talking about sexuality that pervades both individual and institutional levels. Third, novel strategies and solutions proposed by health professionals may help to improve sexuality support. Participants also provided preferences for sexuality training, which they believed should start at university.
Conclusion: Our findings suggest that most health professionals are highly aware of sexuality issues after ABI but fail to adequately address sexuality in individuals post-ABI. This is most likely due to high levels of personal discomfort that is perpetuated by institutional factors. Health professionals believe that there are strategies and solutions that can be employed at both individual and institutional levels that may increase sexuality support for individuals with ABI. However, more research on the potential sexuality-related risks faced by individuals with ABI, causes and treatment of sexuality issues post-ABI, and perspectives of patients and close others is required to provide the evidence-based support and guidelines that health professionals require.
561 Visual deficits and occipital metabolism correlate with levels of consciousness in severe brain injury
Atakan Seltea,c, Leandro Sanza,b, Cecile Andrisa,b,d, Aurore Thibauta,b, Estelle Bonina,b, Stephen Larroquea,b, Claire Bernarde, Roland Hustinxe, Steven Laureysa,b, Arianna Salaa,b, Olivia Gosseriesa
aComa Science Group, GIGA-consciousness, University of Liege, Liege, Belgium, bCentre du Cerveau, University Hospital of Liège, Liege, Belgium, cDepartment of Neurology, University of Wisconsin-Madison, Madison, USA, dDepartment of Ophthalmology, University Hospital of Liège, Liege, Belgium, eDepartment of Nuclear Medicine, University Hospital of Liege, Liege, Belgium
ABSTRACT
Introduction: Severe brain injury can entail a wide spectrum of conditions ranging from unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), emergence (EMCS) and locked-in syndrome (LIS). Visual function is essential for diagnosis, and visual pursuit is frequently observed as first conscious behavior during recovery. This study investigates the relationship between visual impairments, cerebral metabolism and consciousness levels among brain-injured patients. Differently from previous clinical work, this study uses multimodal data to explore brain metabolic activity in addition to ophthalmological features.
Methods: Reports of ophthalmological consultations between 2009 and 2020 were retrieved retrospectively for patients with prolonged severe brain injury from the Liege University Hospital database. Demographic information and 13 ophthalmological features were extracted from the clinical reports of ophthalmological consultations for 61 chronic brain-injured patients (27 females; median age 41yo; median 11.8 months post-injury; 11 UWS, 29 MCS, 17 EMCS, 4 LIS; 25 traumatic). Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) data was retrieved for 50 patients and analyzed using MATLAB 2020a and SPM12 to assess regional metabolism in the occipital lobe and thalamus, as defined by the Automated Anatomical Labeling Atlas, and in the visual network, as defined by the Consensual Atlas of Resting-state Networks. Prevalence of visual impairments and amount of hypometabolic voxels in visual regions (occipital lobe, visual network) and thalamus were stratified by diagnostic group.
Results: 82% patients presented at least one visual impairment (100% UWS, 69% MCS, 53% EMCS, 75% LIS), and a mean number of 1.46 impaired features per patient (out of 13) was observed (UWS 2.64, MCS 1.24, EMCS 1.12, LIS 1.25). Ocular motility (31.2% abnormal, 34.4% not testable), visual fixation (34.4% absent) and visual pursuit (32.8% absent) were the items with the highest rates of impairments. We observed a mismatch between the ophthalmologist’s assessment and the same-day Coma Recovery Scale-Revised (CRS-R), for visual pursuit (n = 4) and fixation (n = 6), the ophthalmologist systematically rated the feature as preserved where the CRS-R examiner did not. The percentage of hypometabolic voxels for the visual network were different (p = 0.037) between the three diagnostic groups (UWS> MCS> EMCS/LIS). The diagnostic groups were compared pairwise, the visual network for UWS was more hypometabolic compared to MCS (p = 0.02) and conscious patients (p = 0.018), while there was no difference between MCS and conscious subjects (p = 0.861). A similar pattern was observed for the right occipital lobe: an overall difference between three groups (p = 0.014), with no difference between MCS and conscious (p = 0.638) and a significant difference between UWS versus MCS (p = 0.020) and UWS versus conscious subjects (p = 0.031).
Conclusions: Most severely brain-injured patients presented visual impairments to some degree, and the severity of clinical deficits as well as posterior metabolism correlated with consciousness levels. These findings confirm the key role of visual pathways in consciousness recovery.
562 “Maybe if this was addressed sooner, maybe things might be different in our relationship. I don’t know. but who knows?” Sexuality after TBI and its place in healthcare: a qualitative exploration of survivors’ experiences
Jill Hwanga, Marina Downinga, Jennie Ponsforda
aMonash University, Clayton, Australia
ABSTRACT
Background: Studies indicate that up to half of individuals with TBI suffer persistent and multi-faceted changes in sexuality that can stem from the physiological, neurological, and psychological sequelae of TBI. However, research exploring in-depth perspectives and experiences around post-TBI sexuality and with receiving support remains limited. This study explored the experiences of individuals with TBI around their post-injury sexuality, whether they felt they were adequately supported by their healthcare team, and their preferences around receiving sexuality support.
Methods: Purposive sampling was used to recruit 20 individuals who were admitted for moderate to severe TBI at the Epworth acquired brain injury rehabilitation unit in Victoria, Australia. Semi-structured interviews were conducted and qualitatively analyzed using reflexive thematic analysis.
Results: Five broad themes were identified. First, there is high variability amongst individuals with TBI in their comfort levels and preferences in discussing sexuality, as well as the nature of their post-TBI sexuality. While some individuals experienced no changes and the small minority experienced hypersexuality, most individuals reported hyposexuality after TBI. Hyposexuality was experienced in the form of erectile difficulties, anorgasmia, reduced desire, and cessation or significantly reduced sexual activity. Second, individuals with TBI have low sexual literacy and sexual awareness. Third, clinical conversations around post-TBI sexuality remain infrequent and limited. Fourth, there is a strong sense of resignation around poor sexuality outcomes. Fifth, basic psychoeducation from clinicians may help these individuals better navigate these sexuality changes.
Conclusion: Our findings suggest that while the majority of individuals with TBI experience changes in sexuality in the form of hyposexuality, they lack the language to define what sexuality means to them and to describe such changes. Limited discussions from their healthcare team means that they are unaware of how sexuality can be impacted after a TBI and of the help-seeking options. Consequently, those who have experienced sexuality-related difficulties are resigned to accepting poorer sexuality outcomes as their “new normal.” While individuals with TBI feel that sexuality should be addressed routinely, the large variability in preferences and comfort levels necessitates a strong person-centered approach to delivering sexuality support.
563 Clinical and research utility of mirna as neurobiological markers of responsiveness to rtms treatment provided to persons remaining in states of disordered consciousness 1 to 2 years after traumatic brain injury
Theresa Bender Papea
aEdward Hines Jr., Va Hospital & Northwestern University, Feinberg School Of Medicine, Hines, USA
ABSTRACT
Recovery from Disorders of Consciousness after traumatic brain injury (DoC-TBI), a neurological disconnection syndrome, is poorly understood. To advance understanding, we conducted a preliminary longitudinal examination of 10 DoC-TBI participants of a double-blind placebo-controlled randomized clinical trial. We examined neurobehavioral gains relative to changes in miRNA expression in response to a neuromodulatory treatment, repetitive Transcranial Magntetic Stimulation (rTMS). Prior to conducting study procedures, all participants were titrated off medications acting on the CNS. Repeated outcome measures included peripheral whole blood derived miRNA and a battery of neurobehavioral tests including the Disorders of Consciousness Scale, the Coma Recovery Scale-Revised, the Coma Near Coma scale and the Disability Rating scale. For miRNA, we determined that 13 of 2589 miRNA significantly changed in expression during active treatment. For these 13 miRNA, we computed peak change during active treatment. After calculating equal interval neurobehavioral measures, we computed neurobehavioral change from baseline to midpoint (15 rTMS sessions) and to endpoint (after 30th rTMS session). For each outcome (miRNA and neurobehavioral measures) we estimated change using mixed effects linear regression models, with a False Discovery Rate of 0.10. This approach was used to produce measures of change that account for inter-dependency of repeated measures and for heterogeneous neuropathology, as indexed by three covariates: volumes of Cerebral Spinal Fluid, Gray Matter and White Matter Density. Correlations were then computed between the estimates of peak miRNA change with neurobehavioral change from baseline to midpoint and to endpoint. Results indicate that change in expression of seven miRNA are significantly (p < 0.05) associated with neurobehavioral gains. Positive neurobehavioral associations indicate a direct correlation between increasing levels of four miRNA (mir 188_5p, 378 f, mir 16_5p and 556_5p) and improved swallowing (r = 0.83 and r = 0.84), visual (r = 0.82), somatosensory (r = 0.65), and overall neurobehavioral (r = 0.62) skills. Inverse neurobehavioral associations indicate direct correlations between decreasing levels of three miRNA (6832_3p; 4638_3p; let_7d_3p) and improving visual skills (R: −0.86, −0.78, −0.63). The miRNA with significant associations are implicated in biological processes including inhibiting cell death, promoting cell proliferation and cell differentiation as well as better recovery. Collectively, the findings demonstrate a relationship between rTMS modulation of molecular pathways regulating neurobehavioral recovery.
564 Understanding your miranda rights: a study of legal language comprehension in adults with traumatic brain injury
Jade Mitchella, Malcolm Edwardsa,b, Kim Walsha, Melissa Duffa
aVanderbilt University, Nashville, USA, bMeharry Medical College, Nashville, USA
ABSTRACT
History of a Traumatic Brain Injury (TBI) has been linked to increased interaction with the criminal justice system and incarceration. For example, individuals with TBI are overrepresented in the prison population in the United States, with a significantly higher percentage of inmates reporting a history of TBI than in the general population. Multiple factors likely contribute to the overrepresentation of individuals with TBI in the criminal justice system. Here, we explore the potential role of cognitive-communication deficits, which may make participation and self-advocacy during criminal proceedings – from Mirandizing to sentencing – arduous. Previous research has demonstrated that individuals with TBI underperform neurotypical peers in tasks of legal language comprehension, such as those associated with the plea colloquy process. Less is known, however, about how individuals with TBI comprehend legal language associated with understanding their Miranda rights. While the specific wording and length of Miranda warnings can vary widely by jurisdiction, language researchers have noted that Miranda warnings frequently use complex syntax, infrequent vocabulary, and nuanced pragmatics. Here, we report on a preliminary study of performance on the Miranda Rights Comprehension Instruments (MRCI). This instrument is widely used in legal settings to assess a person’s understanding of the Miranda warnings and appreciation of the right to silence and the right to counsel. The assessment has four sections: Comprehension of Miranda Rights, Comprehension of Miranda Rights Recognition, Function of Rights in Interrogation, and Comprehension of Miranda Vocabulary. We administered this measure to 12 individuals with moderate-severe TBI and 12 demographically matched neurotypical comparison participants. Participants were recruited from the Vanderbilt Brain Injury Patient Registry and were in the chronic phase of injury (> 6 months post-injury). To conservatively reduce the effects of developmental change and age-related cognitive decline, we restricted age to 20–55 years of age. All participants had between 12 and 14 years of education. As a group, individuals with TBI performed similarly to the comparison group, although individuals with TBI scored numerically lower on all four subtests of the MRCI. This finding suggests that, in this sample, cognitive-communication ability was sufficiently preserved or that cognitive-communication disruptions did not significantly undermine performance. Yet, participants with TBI noted that the assessment was demanding and that they were grateful this was an experiment, not real life. Reflections like this raise the possibility that outside of the controlled laboratory setting, factors such as time pressure, stress, and difficulty with emotion regulation could exert additional forces on cognitive-communication ability and, thus, task performance. Future studies should explore this possibility. More research is needed to understand the factors contributing to the increased interaction with the criminal justice system and incarceration for individuals with TBI and the role of cognitive-communication ability as a risk factor.
565 Goal-setting through participation in a group-based concussion intervention for youth
Kylie Mallorya, Andrea Hicklinga,b, Hiba Al-Hakeema,c, Andrew Lovella, Shannon E. Scratcha,d,e
ABSTRACT
aBloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bDepartment of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, cFaculty of Arts, Humanities and Social Sciences, University of Windsor, Windsor, Canada, dRehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada, eDepartment of Pediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
Background: Approximately 30% of youth with a concussion may experience persistent post-concussion symptoms that can influence their participation in school, sports and other meaningful activities. Move&Connect-Youth (M&C-Y) is a six-week group-based interdisciplinary intervention for youth with persistent post-concussion symptoms that includes physical activity, psychoeducation and goal-setting. Goal-setting is a key component of pediatric rehabilitation that can help youth identify and achieve their goals. The Canadian Occupational Performance Measure (COPM) has been used with youth with a concussion and is commonly used to contribute to goal-setting through the identification of occupational performance issues (OPIs).
Objective: To describe youths’ occupational performance issues and to summarize the role participating in M&C-Y has on goal-setting. METHODS: Ten youth virtually participated in M&C-Y (M = 14.5 years, SD = 1.58 years, Range = 12–17 years). Participants were nine females and one male who experienced their concussion between 3 to 57 months (M = 20.50 months, SD = 17.02 months) prior to participating in the intervention. This study used a mixed methods explanatory sequential design. Participants completed the COPM prior to and after participation in M&C-Y. The COPM is a client-centered, self-report measure that allows the individual to rate OPI importance, performance and satisfaction. Semi-structured interviews with youth were also conducted after program completion to better understand their experience with the intervention. OPIs identified on the COPM were analyzed using descriptive statistics and paired samples t-tests. Interviews were analyzed using conventional content analysis.
Results: Youth identified a total of 43 OPIs using the COPM (number of OPIs ranged from 3–6 per participant). Across the 43 OPIs identified, 12 were self-care, 15 productivity and 16 leisure with all participants identifying at least one leisure and productivity OPI. After participation in M&C-Y, statistically significant changes in performance (M = 1.82, SD = 1.43, t(9) = −4.03, p < 0.01) and satisfaction (M = 2.00, SD = 1.76, t(9) = −3.58, p < 0.01) were found. Almost all participants (90%) had positive changes in performance and satisfaction after participation, with 90% of participants having at least one OPI result in clinically significant changes (a change of two or more) in performance and satisfaction. When reflecting on their experiences with M&C-Y, youth discussed concepts related to: (1) accountability and motivation, (2) the importance of goal-setting and (3) the applicability of goal-setting. Youth highlighted goal-setting as an enjoyable part of the intervention and that the encouraging environment promoted discussion of shared experiences and goals.
Conclusions: Youth that participated in M&C-Y had significant improvements in identified OPIs and emphasized the importance of goal-setting within this intervention. Weekly modeling and review of goal-setting within M&C-Y along with the group-based environment and discussion of shared experiences may positively influence youths’ comfort with and desire to set and achieve meaningful goals.
566 The utility of the overt behavior scale-in session in guiding interdisciplinary communication and treatment for individuals with acquired brain injury in an inpatient rehabilitation setting
Ileana Herrina, Lindsey Harika, Chynah Blankenshipa, Elizabeth Larkina, Rachelle Wilmorea, Christopher Falcoa, Glenn Kellya, Grahame Simpsona
aTIRR Memorial Hermann, Houston, USA
ABSTRACT
Introduction: Challenging behaviors (CB) such as verbal and physical aggression, sexualized behaviors, disinhibition, and restlessness are common following acquired brain injury (ABI). CB pose a number of barriers to participation in rehabilitation programs and community integration (Kelly, et. al., 2008; McAllister, 2013). Standardized assessment of CB can aid in guiding intervention planning for best functional outcomes (Janzen, et. al., 2014). The Overt Behavior Scale-In Session (OBS-INS) was modified from a similar community outcome measure to assess CB in adults with ABI within an inpatient rehabilitation facility (IRF) in order to guide interdisciplinary communication and intervention planning for more optimal outcomes and safe rehabilitation stays and discharges. A validation study was performed, comparing the OBS-INS to the Agitated Behavior Scale (ABS), which is currently widely recognized as the standard for measurement of aggression and agitation in adults with ABI (Corrigan, 1989). Results revealed a high correlation between the OBS-INS and ABS at admission (r = 0.815) and discharge (r = 0.718) and a high correlation in responsiveness (r = 0.790) Preliminary qualitative findings revealed that rating clinicians found the OBS-INS improves interdisciplinary communication. The Neurobehavioral (NB) Program at TIRR Memorial Hermann aims to provide competent and effective care for adults with ABI complicated by CB. The purpose of the current study aims to assess the overall utility of the OBS-INS in guiding interdisciplinary communication and treatment for better functional outcomes and safer discharges back to the community.
Method: As part of a program improvement project, the OBS-INS was used to determine inclusion criteria to the NB Program due to demonstration of challenging and unsafe behaviors CB. A survey was administered to rehabilitation staff to determine whether interdisciplinary use of the OBS-INS aids in guiding NB Program designation, intervention planning, and discharge disposition.
Results: Results will determine if the OBS-INS can accurately and effectively capture patients that need to be designated to the NB Program as well as guide intervention and discharge planning for more functional outcomes in individuals with CB following ABI.
Conclusion: Through interdisciplinary use of the OBS- INS, a more common language to describe CB may be used to discuss and determine intervention and discharge plans for more successful and safe community integration. These results may be beneficial in guiding other neurobehavioral programming for improved functional outcomes of this unique patient population.
567 Exploring the role of facebook in supporting social connection for individuals with traumatic brain injury (TBI)
Catalina L. Tomaa, Juwon Hwangb, Lisa Kakongec, Emily L. Morrowd,e,f, Lyn S. Turkstrac, Bilge Mutlug, Melissa C. Duffd
aDepartment of Communication Arts, University of Wisconsin-Madison, Madison, USA, bSchool of Media and Strategic Communications, Oklahoma State University, Stillwater, USA, cSchool of Rehabilitation Science, McMaster University, Hamilton, Canada, dDepartment of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, USA, eDepartment of Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, USA, fCenter for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, USA, gDepartment of Computer Sciences, University of Wisconsin-Madison, Madison, USA
ABSTRACT
Traumatic brain injury (TBI) can cause major disruptions in individuals’ social lives, with research documenting significant increases in loneliness, loss of friends, and decreased social participation in this population. Uninjured adults report a range of social benefits derived from social media, but whether this also applies to individuals with TBI remains an open question. This study examined (a) whether individuals with TBI preferred to self-disclose on Facebook compared to face-to-face interactions; and (b) if Facebook self-disclosure facilitated relational maintenance behaviors and, in turn, increased closeness with Facebook “friends” for this population. Participants were 53 individuals with moderate-severe TBI (28 women; age M = 37.7, SD = 9.6) and 51 uninjured individuals (29 women; age M = 36.5, SD = 10.4) matched for age and education to the TBI group. All participants were recruited through the Vanderbilt Brain Injury Patient Registry and filled out an online survey regarding their Facebook use. Using previously validated scales, participants reported their preference for self-disclosure on Facebook compared to face-to-face interaction (e.g., “It is easier to disclose personal information on Facebook than in person”); the extent to which they engaged in relational maintenance behaviors on Facebook (e.g., “I send messages to my Facebook friends”); and the extent to which they experienced relational closeness with their Facebook friends (e.g., “My relationships with my Facebook friends are close”). Results showed that adults with TBI reported a significantly higher preference for self-disclosure on Facebook than uninjured adults, t(83) = 2.86, p < 0.05. A mediational analysis revealed that, among uninjured adults, preference for self-disclosure on Facebook was associated with more relational maintenance behaviors on Facebook, b = 0.15, p < 0.01, and, in turn, with greater relational closeness with Facebook friends, b = 0.31, p < 0.05. However, these relational benefits did not emerge for individuals with TBI. Among this group, preference for disclosure on Facebook was not associated with either relational maintenance behaviors on Facebook, b = 0.10, p > 0.05, or with relational closeness with Facebook friends, b = 0.07, p > 0.05. These results document a greater preference for Facebook self-disclosure for adults with TBI than uninjured adults, presumably because Facebook provides a series of features that can assist with TBI-related physical and cognitive limitations (e.g., unlimited time to compose messages, the ability to divert cognitive resources toward self-disclosure). However, this preference for Facebook self-disclosure did not materialize into relational benefits for adults with TBI, even though it did for their uninjured peers. These results raise questions about how relational maintenance on social media relates to known challenges with interpersonal communication and friendships in adults with TBI, and suggest a need for Facebook modifications to support effective use of social media to increase social participation.
569 Spiral “concussion” curriculum fostering resident competency acquisition: a 6-month impact study
Alice Kama, George Zhaoa, Aisha Husaina, Ching-Lung Huanga, Joyce Nyhorf-Younga, Fatima Khana, Aly Summersa, Denyse Richardsona
aUniversity of Toronto, Toronto, Canada
ABSTRACT
Background: Current literature identified a lack of concussion curriculae focusing on changes in patient outcomes. With the implementation of Rowan’s Law in Ontario, Canada, there is an urgent need for concussion education in primary care to support resident competency acquisition.
For competency acquisition, teaching practices promoting competency acquisition are a core component of competency-based education (CBE); however, current literature lacks teaching practices impacting competency acquisition, specifically the impacts of a Spiral Curriculum, which integrate various horizontal and vertical teaching techniques. This study explores the impacts of a Spiral Concussion Curriculum (SCC) on resident concussion competency acquisition.
Method: A prospective cohort comparison study of SCC was incorporated into two family medicine residency sites (n = 34) with an iterative usability approach. The first cohort (n = 15) was exposed to Flipped Classroom (FC), workplace learning, and self-reflection. The second cohort (n = 19) was exposed to the same teaching techniques plus an additional peer teaching FC for engagement. Residents’ knowledge, confidence in their competency, behavior change, and strategies for competency acquisition at six months were evaluated. Data analysis was undertaken using a constructivist, inductive qualitative framework and SPSS quantitative analysis.
Result: Residents in the second cohort (n = 7) had a knowledge increment of 11.58% [pretest mean (M) score 11.14 out of 18 multiple choice questions; 6-month-delayed-post test mean 12.43/18; p = 0.093] (versus first cohort: n = 5; M: 11.6 out of 18; delayed-post M: 11 out of 18; minus 3.33%) and higher confidence in competency at 62.79% [5 point Likert scale; pre-intervention M: 2.15; n = 13; delayed post M: 3.5; n = 8; p = 0.0014] versus first cohort of 30% confidence increment (n = 5; pre-intervention M: 4; delayed-post M: 7.6; p = 0.025). Residents (5 out of 6) reported positive behavioral changes at 6 months and that Spiral Design allows frequent revisiting and deeper dive into concussion.
Discussion: This is the first competency acquisition study of SCC. In addition, this is the first long-term spiral impact study in concussion. Even though this study size is small, the findings validate the use of Spiral Design in CBE. Further studies should focus on exploring the impact of Spiral Design on mechanisms of learning to further develop CBE teaching practices in residency education.
570 Clinical implementation of an education tool applying the CRS-R framework for pediatric patients with disorders of consciousness in an acute neurorehabilitation setting
Sarah Tlustosa, Caroline Freera, Amanda Chestnuta, Kilby Manna
aChildrens Hospital Colorado, Aurora, USA
ABSTRACT
Children with disorders of consciousness (DoC) secondary to an acquired brain injury require deliberate care in the acute neurorehabilitation setting and often benefit from interdisciplinary team support. The gold standard for behavioral and clinical assessment of DoC continues to be the Coma Recovery Scale Revised (CRS-R), and the adapted version for children, the Coma Recovery Scale for Pediatrics (CRS-P). Yet, the language used for classifying neurocognitive status in the CRS-R/P can be challenging for patients’ families and clinicians to interpret and understand how this relates to the child’s rehabilitative goals. An educational tool created by clinicians at Childrens Hospital Colorado details the characteristics expected in each stage of recovery through DoC, the functional implications of these characteristics and the associated expected plan of care from the interdisciplinary team including therapies, neuropsychology and medicine specialties. The goal for this tool is to support clinician and family’s understanding of their child’s behavior within the context of their stage of recovery, and to support their ability to engage in evidence-based rehabilitative practices. At its best use, the educational tool can provide an avenue for family education at each stage, as well as support consistency in messaging and care provision by clinical staff.
571 Traumatic brain injury and baseline factors associated with changes in longitudinal mri measures of brain structure among individuals living in homelessness or precarious housing
Jacob Stubbsa, Kristina Gicasb, Andrea Jonesa, Alexandra Vertinskya, Manraj Herana, Wayne Sua, Breanna Nelsona, Ava Griera, Donna Langa, Thalia Fielda, Allen Thorntonc, Alasdair Barra, Olga Leonovaa, George MacEwana, Alexander Rauschera, William Panenkaa, William Panenkaa
aUniversity Of British Columbia, Vancouver, Canada, bYork University, Toronto, Canada, cSimon Fraser University, Burnaby, Canada
ABSTRACT
Background: Homeless or precariously housed individuals face health challenges and higher mortality compared to the general population. Emerging evidence suggests that these individuals have impaired magnetic resonance imaging (MRI) measures of brain structure and poorer health compared to the general population, but the role of traumatic brain injury (TBI) and other factors on the longitudinal change in these MRI measures remains unknown.
Objective: Our objective was to evaluate how history of TBI, substance use, HIV, and cardiovascular disease risk were associated with baseline and longitudinal changes in MRI measures of brain structure among these individuals.
Methods: We used data from an ongoing longitudinal observational study of individuals living in homelessness and precarious housing in an impoverished neighborhood of Vancouver, Canada. Longitudinal brain MRIs were collected over 12.5 years, along with monthly and yearly assessments of health and functioning. Change in brain macrostructure was assessed with T1-weighted scans and change in brain microstructure was assessed with diffusion tensor imaging scans. We used linear-mixed effects regression to evaluate how history of TBI, substance use, HIV, and cardiovascular disease risk were associated with baseline and longitudinal changes in MRI measures of brain structure. We used multiple linear regression to evaluate how change in MRI measures were associated with health and functioning.
Results: 300 participants with longitudinal brain MRIs and health measures were included (1141 total pairs of scans; median number of scans per participant = 3; avg. time between first and last scan = 5.4 years). In the study sample, 59% had a history of any TBI and 31% had a history of moderate or severe TBI at baseline. History of TBI was associated with more whole-brain atrophy at baseline (β = −0.26, p = 0.11), and alcohol dependence (β = −0.06, p < 0.0001) and cardiovascular disease risk (β = −0.02, p < 0.0001) were associated with more rapid atrophy over time, adjusting for age, sex, and baseline comorbidities. Opioid dependence was associated with lower baseline whole-brain fractional anisotropy (β = −0.19, p = 0.041) and history of TBI (β = −0.02, p = 0.040) was associated with more rapid decline in fractional anisotropy over time, adjusting for age, sex, and baseline comorbidities. Greater rates of whole-brain atrophy and decline in whole-brain fractional anisotropy were associated with mortality during the study period (ps < 0.015), decline in physical health (ps < 0.008), and decline in cognitive functioning (ps < 0.009).
Conclusions: Traumatic brain injury is common among individuals living in homelessness and precarious housing and, along with specific substance dependences, is associated with more rapid decline in MRI measures of brain health. Targeted assessment and interventions may be warranted in order to address the health challenges faced by these individuals.
573 Movement disorders after traumatic brain injury: an observational study
Ryan Wanga, Douglas Katza,b, Stephanie Bissonnettea,b, Brigid Dwyera, Rachel Hooverb
aBoston Medical Center, Boston, USA, bBoston University, Boston, USA
ABSTRACT
Trauma to the central nervous system is a recognized causative factor for a variety of secondary movement disorders, including tremor, dystonia, dyskinesia, myoclonus, and parkinsonism. Prior observational studies in movement disorder clinic populations have characterized a significant prevalence of movement disorders following traumatic brain injury (TBI). However, due to the diverse nature of these movement disorders and frequent delayed onset to presentation, the available literature on post-TBI movement disorders is limited. There is a paucity of information on the incidence and prevalence of post-TBI movement disorders in a TBI population followed longitudinally over an extended period.
Methods: Retrospective review of patients followed in an academic university TBI subspecialty clinic (Boston Medical Center). All patients evaluated for sequelae of TBI by a neurologist (Brain Injury Medicine subspecialist) between 07/01/2021 to 06/30/2022 were screened for inclusion. The majority were follow-up evaluations. For each patient, electronic medical records were screened for any type of movement disorder and information was extracted from previous records, including older paper charts, to characterize TBI severity, type of movement disorder (tremor, ataxic limb, parkinsonism, dyskinesia, dystonia – distinct from spasticity or contractures), onset, and course.
Results: The study population consisted of 217 patients with mild (43.1%), moderate (10.2%), or severe (46.7%) TBI according to conventional criteria, based on Glasgow Coma Scale, duration of unconsciousness or post-traumatic amnesia. A movement disorder was identified in 62 of 217 (28.6%) patients. Of those with movement disorders, the highest proportion had sustained severe TBI (69.4%). Only 24.2% of patients with a movement disorder had sustained a mild TBI. Among the 62 patients with movement disorders, categories included: tremor (40), parkinsonism (13), dystonia (13), ataxia (10), or other type of movement disorder (4).
Conclusions: A substantial proportion of patients with TBI develop movement disorders, most with severe TBI. Action tremor is by far the most common type of post-TBI movement disorder and movement disorders often have a delayed onset.
574 Adverse childhood experiences in adults with moderate-severe traumatic brain injury: relevance to current psychological distress and health-related quality of life
Umesh Venkatesana,b, Stephanie Wolferta
aMoss Rehabilitation Research Institute, Elkins Park, USA, bSidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA
ABSTRACT
Background: The negative associations between adverse childhood experiences (ACEs) and multiple aspects of health, particularly mental/behavioral health, have been widely documented in the general population. Recent literature suggests that adults living with traumatic brain injury (TBI) have experienced greater adverse childhood experiences (ACEs) than adults in the general population. Therefore, ACEs may play a role in behavioral health after TBI independent of injury-related effects.
Objective: The principal aims of the current pilot observational study were to: 1. determine the prevalence of household-level (e.g., violence in the home) and community-level (e.g., neighborhood violence) ACEs in a local sample of people with chronic moderate-severe TBI, and 2. examine the relationship between ACEs and two commonly measured behavioral health outcomes of TBI – psychological symptoms and health-related quality of life (HRQoL).
Methods: Participants included 85 individuals with medically confirmed moderate-severe TBI consistent with TBI Model Systems criteria (age = 50.8 ± 14.8 years; 28 Female, 57 Male; 52.9% White, 37.6% Black, 9.4% Other; 13.6 ± 2.9 years of education) sustained at least 1 year prior to study enrollment (chronicity = 10.3 ± 5.5 years). Participants completed study questionnaires during a single, in-person session. Measures included the Philadelphia ACE Questionnaire for 9 household-level and 5 community-level ACEs; the Brief Symptom Inventory-18 Item for psychological symptom severity (subdomains and overall distress); and the Quality of Life after Traumatic Brain Injury questionnaire for HRQoL. Inferential statistical analyses included correlations, hierarchical linear regression, and mediation modeling with bootstrapping.
Results: Medians for household/community ACEs were 2/1, with 78.8%/67.1% of the sample reporting at least 1 household/community ACE. The total number of ACEs showed significant relationships with depression, anxiety, and somatization symptoms (ρs = 0.36–43, ps< 0.001); with overall psychological distress (ρ = 0.42, p < 0.001); and with HRQoL (ρ = −0.24, p = 0.03). After accounting for demographic and injury-related covariates, total ACEs explained 13% additional variance in psychological distress (p < 0.001) and 8% additional variance in HRQoL (p = 0.008). A significant portion of the effect between total ACEs and HRQoL was explained by psychological distress in both unadjusted and covariate-adjusted models (ps< 0.001).
Conclusions: The study findings indicate that ACEs are uniquely associated with psychological symptoms and HRQoL after major neurotrauma, consistent with the hypothesis that ACEs are lifetime risk factors for poor behavioral health. The effects of ACEs on post-TBI health may also be indirect, operating via psychological distress. In clinical research and care settings, rehabilitation professionals should consider to what extent conventionally regarded “TBI outcomes” are in fact life-course outcomes that may require interventions contextualized within the personal and social histories of individual patients. At the healthcare system level, the degree to which ACEs may reflect structural disadvantages should be examined to motivate policy evaluation and change related to TBI rehabilitation and long-term disability management.
575 Challenges and lessons learned delivering contextual based brain injury intervention: it’s more than just making a Lasagna!
Deidre Sperrya, Katie Pasquinia, Heather deBoera
aMcMaster University, Hamilton, Canada
ABSTRACT
Background: It is a widely agreed upon principle that the optimal environment for the delivery of rehabilitation is the environment in which the activity takes place. The Life Redesign Model™ is described as an innovative functional approach to have people participate in real-life activities, which are embedded with rehabilitation activities. This contextually based rehabilitation environment is rich with opportunity for the rehearsal of a myriad of skills. Clinicians across the rehabilitation disciplines endeavor to work in real life type settings as a way to incorporate these best practices, but this is not without challenge. In many rehabilitation environments regulated health professionals routinely assign remedial programming to support staff to implement in real life situations. The support staff are often less trained in observational skills and thus any challenges are magnified. In real life, physical and cognitive demands occur simultaneously and require a sharp set of observational skills. It is critical for all those working in brain injury rehabilitation to have skills that allow them to see beyond the task at hand and evaluate multiple skills at the same time. The Rehabilitation Treatment Specification System (RTSS) provides clinicians the model by which we can begin to analyze, design and measure treatment programs. Knowing what to do, is much different than knowing how to do it; and guidance in bridging this gap is only beginning to emerge.
Objective: The objective of this project was to incorporate the RTSS into the development of methods and tools to support cross discipline staff become better observers of physical, cognitive, social, and emotional skills in real life environments.
Methods: At a specialized, residential brain injury rehabilitation program based on the Life Redesign Model™ of care, five real-life activities were analyzed by a multi-disciplinary team. Together the team used the RTSS to identify the ingredients, mechanisms of action, aims and potential targets for each activity. Additionally, each activity was prepared in a way to easily identify the physical, cognitive social and emotional demands, as well as the potential rehabilitation opportunities inherent in each activity. Front line staff – Life Redesign Coaches were provided with training using these tools to improve their ability to observe these identified activities as they occur in the real-life environments.
Outcome: This project will share the details of what tools were developed and methods used to train cross discipline staff. As part of this reflection, preliminary challenges and successes will also be shared.
578 Novel imaging signatures to detect rod microglia after experimental diffuse traumatic brain injury
Katherine Giordanoa,b, Daniel R Griffithsa,b, Elizabeth B Hutchinsonc, Jonathan Lifshitza,b
aUniversity Of Arizona College Of Medicine-Phoenix, Phoenix, USA, bPhoenix VA Health Care System, Phoenix, USA, cUniversity of Arizona Department of Biomedical Engineering, Tucson, USA
ABSTRACT
Inflammation and associated microglial activation are pathological features of clinical and experimental traumatic brain injury (TBI). After experimental diffuse TBI, we reproducibly report an abundance of rod microglia (a morphological variant of activated microglia) that align across the primary somatosensory cortex adjacent to neurons in foci of neuropathology using immunohistochemistry (IHC) for nonspecific microglia antibodies (Iba-1). Clinically, rod microglia have been reported in postmortem Alzheimer’s disease, epilepsy, stroke, and Autism spectrum disorder. Without specific markers for their detection, rod microglia investigations are limited to postmortem observation by IHC. Conventional in vivo brain imaging techniques (CT, MRI) lack the sensitivity to detect microscale changes associated with microglia morphology. Detection requires discovery of specific markers and imaging signatures of rod microglia. With new tools developed to detect rod microglia activation, their role in diagnosis, prognosis, or therapy can be determined. In this study, we hypothesized that rod microglia could be detected by diffusion magnetic resonance imaging (dMRI) after diffuse TBI. Male and female rats (262–384 g) received midline fluid percussion injury. Brain tissue was collected at 7 days post-injury and fixed for high resolution ex vivo diffusion MRI microscopy including diffusion tensor imaging and mean apparent propagator imaging. An imaging signature of increased restriction, especially in the direction of the rod microglia long axis was detected in the primary somatosensory cortex of injured brains. The location and extent of this MRI abnormality corresponds with known rod microglia pathology. Confirmation of rod microglia pathology with IHC will validate the imaging signature. Overall, we continue to investigate rod microglia, which could represent the histological manifestation of neuropathology and/or repair mechanisms after TBI. Ultimately, rod microglia are positioned at critical junctions in injury and disease progression, whereby detecting and tracking them in vivo using imaging signatures can guide diagnosis and prognosis.
Funding: NINDS F31NS113408, Arizona Alzheimer’s Consortium, Brain Injury Association of America
579 More than just wearing a mouthguard: a multi-modal approach to concussion prevention in youth rugby
Stephen Westa,b,c, Isla J. Shilla,d, Carolyn A. Emeryb,c,d,e,f,g,h
aCentre for Health, Illness, and Injury Prevention in Sport, Department for Health, University Of Bath, Bath, United Kingdom, bSport Injury Prevention Research Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, cO’Brien Institute of Public Health, University of Calgary, Calgary, Canada, dHotchkiss Brain Institute, Calgary, Canada, eAlberta Children’s Hospital Research Institute, Calgary, Canada, fDepartment of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada, gDepartment of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada, hMcCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
ABSTRACT
Background: There is a growing need for strategies targeted at preventing concussions at all levels and ages of rugby. There is growing evidence surrounding the short- and long-term consequences and burden of concussion in youth rugby participants as well as the health care system. With the growing base of evidence for multiple concussion prevention strategies in many sports, consideration of a multimodal approach to prevention should be considered.
Objectives: We will demonstrate the importance of an evidence-based multi-modal approach to concussion prevention across the domains of policy/law change, training strategies and protective equipment.
Methods/ Results: Within the context of rugby from grassroots to the developing youth athlete, policy change has the potential to impact the greatest number of youth participating in the sport. For example, several ongoing law trials globally aimed at a reduction in the legal tackle height are being implemented, as well as discussions regarding the age of introduction to contact. Based on our data, 2 of more years of previous rugby playing experience do not protect against tackle related concussion compared with no playing experience, therefore suggesting the age of introduction could be raised without harmful consequences (Male RR: 1.58: 95%CIs: 0.71–3.53; Female RR: 1.18; 95%CIs: 0.75–1.87). Similarly, neuromuscular training (NMT) warm-ups targeted at male youth rugby players have revealed significant reductions in concussion rates of up to 59% in youth players. We will share new findings in the youth female game. The final domain of prevention involves personal protective equipment (e.g., mouthguards and headgear, and helmet fit). Importantly, the adoption of multiple sustainable solutions to minimize the risk of concussion is crucial to have a significant public health impact on concussion rates in youth rugby. The evidence for prevention strategies in isolation is consistently positive. However, the additive effect of multiple domains must be considered to maximize the concussion prevention potential.
Conclusions: Concussion in sport is complex in nature and the strategies we implement and evaluate aimed to prevent concussion occurrence must be multifactorial. Current research evidence from across youth sports informing best practice and policy in concussion prevention suggests the adoption of training programs such as neuromuscular training as standard of practice as well as widespread utility of personal protective equipment and important game wide policy/rule considerations. The prevention of concussion must adopt a multi-stakeholder and multi-modal process to maximize the welfare of youth sport participants to ensure lifelong participation.
580 More than just counting concussions: a multi-modal approach to concussion risk factor and prevention evaluation in youth rugby
Stephen Westa,b,c, Isla J. Shillb,d, Taylor Priceb, Carolyn A. Emeryb,c,d,e,f,g,h
aCentre for Health, Illness, and Injury Prevention in Sport, Department for Health, University of Bath, Bath, United Kingdom, bSport Injury Prevention Research Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, cO’Brien Institute of Public Health, University of Calgary, Calgary, Canada, dHotchkiss Brain Institute, University of Calgary, Calgary, Canada, eAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, fDepartment of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada, gDepartment of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada, hMcCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Canada
ABSTRACT
Background: In North America, over 3 million people sustain a concussion annually, with 50% occurring in children and adolescents. As such, the prevention of these injuries is vital to minimize the health burden on both the players and healthcare systems. The prevention of concussion, and all injury types, has historically relied heavily on prospective injury surveillance data to support the evaluation of their effectiveness. While injury surveillance data continues to be the gold standard methodology associated with the evaluation of prevention strategies, modern developments in technology have led to the utility of new measures in evaluating the effectiveness of injury prevention strategies.
Objectives: The purpose of this abstract is to outline the need to utilize multiple emerging technologies to support the evaluation of prevention strategies through injury surveillance. Secondarily, we will outline how employing a multi-modal approach to prevention evaluation can provide more insight into the mechanism of concussion than surveillance alone, therefore informing concussion prevention.
Methods/Results: Injury surveillance remains the foundation of our evaluation of prevention strategies, however with the evolution of web-based platforms including athlete management systems and electronic medical note-keeping systems, the processes associated with injury surveillance have been streamlined and customized to meet the needs of research participants and researchers alike. To further our understanding of injury mechanisms and to inform concussion prevention, current supplementary technologies commonly used include video analysis and instrumented mouthguards (iMGs) in youth sport. Video analysis has been extensively used in recent years to investigate mechanisms of head impacts and concussion in youth sport. iMGs inform a greater understanding of the frequency, magnitude, and location of head impacts, which, alongside the contextual information provided by video analysis provides a more holistic picture of concussions and how we might prevent them. Through injury surveillance, we have captured a rate of concussion which is 1.7 times higher in females than males (RR: 1.70; 95%CIs: 1.08–2.69). Surveillance also demonstrates that 79% of male and 76% of female concussions are because of the tackle. Building on this work, video analysis has demonstrated an almost 5-fold higher risk of concussion in u13 females compared to u13 males (RR:4.75; 95%CIs: 1.12–22.91) and provided insights into the tackle characteristics associated with concussive tackles. Furthermore, comparing U13 girls to u16 (RR:9.98; 95%CIs: 2.54–41.35) and U18 girls (RR:1.98: 95%CIs:0.47–9.53) has demonstrated the need for further resource allocation to support the introduction of the tackle in this group.
Conclusions: Concussion and the prevention of concussion is multifactorial in nature. As such, the methods used to evaluate the effectiveness of prevention strategies should be multi-modal. While retaining the vital information captured through injury surveillance, we must continue to evolve our evaluation of concussion prevention strategies through new technologies including video analysis and iMGs.
582 The assessment and rehabilitation of verbal operants following acquired brain injury: a pilot series
Megan Heinickea, Kimberly Magat-Mabantaa, Dani Buckleya
aCalifornia State University – Sacramento, Sacramento, USA
ABSTRACT
Although verbal deficits are a major concern for individuals following an acquired brain injury (ABI), behavior-analytic research on language training in neurorehabilitation settings is extremely limited, and behavior analysts serving this growing consumer group do not have a validated, function-based assessment to guide their language programming. The purpose of this pilot series was twofold. First, we systematically replicated the work of Sundberg, San Juan, Dawdy, and Arugelles (1990) in which the authors evaluated the acquisition and functional interdependence of verbal operants for adults following ABI. We used slightly modified procedures (inclusion of high-preference activities, progressive prompt delay) and compared acquisition rates of tacts, mands, and intraverbals with three adult ABI survivors. We also assessed whether directly training one verbal operant led to the emergence of untrained, topographically similar verbal operants. Contrary to Sundberg et al., we found mand training was successful for all participants and led to the greatest amount of transfer under tact conditions, and we offer potential explanations for our differing results. Second, Gross, Fuqua, and Merritt (2013) developed and piloted the Verbal Behavior Assessment Battery (VBAB) to evaluate language deficits for older adults with neurocognitive disorder or dementia, but researchers have yet to replicate this study or evaluate this tool for adults following ABI. We expanded the VBAB to better capture the complex changes that may occur following ABI. We conducted a revised assessment with four adults with moderate-to-severe ABI and one healthy control participant and found 1) similar deficit areas for three of the four experimental participants, 2) error patterns indicating both functional independence and interdependence of verbal operants, and 3) preliminary support for test-retest reliability. Our discussion is focused on methodological considerations and potential refinement of the assessment for future clinical use.
585 Examining the long-term associations between intimate-partner violence-related brain injuries and balance, neurobehavioral symptoms, and psychological distress in a sample of community women
Eve Valeraa,b, Annie-Lori Josepha, Sarah Kingb
aHarvard Medical School, Boston, USA, bMassachusetts General Hospital, Boston, USA
ABSTRACT
Background: Intimate partner violence (IPV) is the leading cause of homicide for women globally as well as the most common form of violence against women. It is a global public health crisis affecting up to 33% of women worldwide. Despite many reports showing that most physical abuse is to the neck and higher, there is very little recognition or study of the effects of IPV-related brain injuries (BIs). Anecdotally, women with histories of IPV-related BI have reported problems with balance. However, there are no studies we are aware of that have examined the relationship between balance/postural sway, and history of IPV-related BI. Furthermore, the few studies that have linked IPV-related BIs to increased levels of psychological stress or neurobehavioral symptoms have largely been conducted with women living in shelters or seeking IPV assistance. In other words, most of these women were still in or had only recently left an abusive relationship and may have sustained recent BIs.
Objective: The objective of this study was to examine the long-term associations between IPV-related BIs and measures of sway, psychological distress, and neurobehavioral symptoms in a sample of women in the community (non-shelter).
Methods: To be included, participants needed to identify as women and report at least one instance of physical IPV. For this preliminary interim analysis of our ongoing study, 87 women were included. Women were administered the Brain Injury Severity Assessment Interview (BISA) as well as the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), the PTSD Checklist-5 (PCL-5) and the Neurobehavioral Symptom Inventory (NSI). Postural sway was measured with the Sway Balance system (higher scores represent better postural stability).
Results: Sixty-four percent of women reported at least 1 IPV-related BI with 42% reporting repetitive BIs. The most recent IPV-related BI was over 1 year ago for 94% of the sample. Spearman’s correlations showed significant positive correlations between number of IPV-related BIs and the total neurobehavioral symptom score (ρ = 0.23, p < 0.05) as well as anxiety (ρ = 0.29, p < 0.01). The correlations between number of IPV-BIs and total sway score (ρ = −0.185, p = 0.09) and IPV-BIs and posttraumatic stress (ρ = 0.186, p = 0.09) approached standard levels of statistical significance.
Conclusions: These data replicate other findings indicating high rates of single and repetitive BIs in women who have experienced IPV. Importantly, these data also show that high rates of IPV-BI can be found in community samples of women. The data also indicate that long after sustaining IPV-BIs, women with more IPV-BIs are at higher risk for experiencing anxiety and neurobehavioral symptoms. The data are inconclusive regarding increased risk for balance (sway) and posttraumatic stress symptoms, but this will be clarified as our data collection concludes.
586 Prevalence of concussion-like symptoms and reporting behaviors among collegiate athletes in Canada: an opportunity to improve concussion education
Amanda Blacka,b,c,d, Aura Wetherella, Kate Turcottee, Taryn Taylorf, Shazya Karmalie, Shelina Babule,g
aSport Injury Prevention Research Center, Faculty of Kinesiology, University of Calgary, Calgary, Canada, bAlberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada, cHotchkiss Brain Institute, University of Calgary, Calgary, Canada, dO’Brien Institute for Public Health, Calgary, Canada, eBC Injury Research and Prevention Unit, BC Children’s Hospital, Vancouver, Canada, fCarleton Sport Medicine Clinic, Carleton University, Ottawa, Canada, gDepartment of Pediatrics, University of British Columbia, Vancouver, Canada
ABSTRACT
Background: Sport-related concussion (SRC) is a common but challenging health concern at the university level. Student-athletes not immediately removed from play following an SRC may suffer from more severe symptoms and prolonged recovery. Currently, concussion identification relies heavily on athletes recognizing concussion symptoms and reporting them to their coach or team therapist. However, reporting behaviors depend on culture and geographical factors. More literature is needed specifically on Canadian varsity-level athletes.
Objective: To examine the prevalence of concussion symptoms and reporting behaviors among Canadian varsity level athletes.
Methods: This is a secondary cross-sectional analysis of a pre-experimental study examining a new concussion education intervention. University administrators and therapists at all 56 U SPORTS affiliated institutions were provided with a link to a validated survey for their athletes to complete between September 2020 and March 2021, before completing a new concussion education tool. In addition to demographic information, this survey requested players to self-report if they experienced symptoms immediately following a hit, within the last 365 days, and whether they reported it. Descriptive statistics were used to understand the prevalence of reporting behaviors.
Results: In total, 1,017 student-athletes from 16 universities participated in the survey (472 males, 542 females, 3 preferred not to respond; median age(range): 20(17–33)). Most athletes in the sample participated in soccer (18.19%), hockey (17.40%), volleyball (13.47%), or football (12.59%). Approximately 83% reported receiving prior concussion education, and 48% reported thinking they had sustained at least one concussion in their lifetime. In the past year, student-athletes reported the following symptoms following an impact: dizziness 182/1011 (18.00%), having their bell rung 212/1013 (20.93%), lost consciousness or black out 19/1010 (1.88%), seeing stars 112/1014 (11.05%), vomiting or nausea 51/1013 (5.03%), forgetting what to do on the rink, court or field 42/1014 (4.14%), at least one headache within a week 219/1012 (21.64%), or having problems studying, concentrating or doing class work 122/1012 (12.06%). In total, 163/1013 (16.09%) reported the above symptoms but did not immediately tell a coach or team therapist and kept playing, and 60/1011 (5.93%) continued to have symptoms the day after a hit but did not tell anyone. Out of the 340 athletes who reported at least one symptom, 225 (66.17%) reported that they did not think they had sustained a concussion in the last year despite their symptoms.
Conclusions: Approximately 1 in 6 Canadian varsity student-athletes do not immediately tell their coach when experiencing concussion signs or symptoms. This study highlights the importance of new, innovative targeted concussion education, e.g., the Concussion Awareness Training Tool for High Performance Athletes (CATT-HPA). The CATT-HPA is a new online education program designed to address Canadian varsity student-athlete knowledge and change concussion management using evidence-based behavior change strategies.
587 Social media building blocks: a systematic literature review on the use of computer-mediated communication (CMC) and social media to support social participation in adolescents with acquired brain injury (ABI)
Sam Hosseini-Moghaddamb, Lisa Kakongea, Minseo (Sunny) Kimc, Jamila Turkstrad, Lyn S. Turkstraa
aSchool of Rehabilitation Science, McMaster University, Hamilton, Canada, bUniversity of Toronto Schools (UTS), Toronto, Canada, cFaculty of Health Sciences, McMaster University, Hamilton, Canada, dFaculty of Humanities, McMaster University, Hamilton, Canada
ABSTRACT
Adolescents today are the most common users of computer-mediated communication and social media. A plethora of studies have investigated the experience of social media use in adults with acquired brain injury (ABI), but there have been few studies on CMC and social media use in adolescents with ABI, as well as the potential for social media to support social participation. The primary objective of our study was to conduct a systematic literature review as the first step of an exploratory sequential mixed methods research study on CMC and social media use in adolescents with ABI. We searched five databases, including CINAHL, Ovid Medline, APA PyscInfo, AMED, and Embasse, for peer-reviewed articles published from 1982 to July 14, 2022. We hand-searched reference lists of articles for additional relevant citations. In addition, we searched the gray literature for keywords on CMC, social media use, adolescents, and adolescents with ABI. Articles with the following keywords and Medical Subject Headings (MESH) were included, using the Boolean operator “and”: 1) Computer mediated communication.mp; 2) social media, or internet, or computer communication; 3) adolescent*, teen*, youth; and 4) brain injury*. Data was abstracted into an Excel spreadsheet and analyzed by two researchers for articles that included the search terms. The database search yielded a total of 0 articles across all five databases when all four search terms were combined with the Boolean operator “and.” A review of the gray literature and hand-search of references yielded 31 relevant articles that addressed general CMC and social media use in adolescents. A full-text review of the articles from the hand-search of references and the gray literature yielded the following key themes: an emphasis on the perils of adolescent social media use; the perceived benefit of active versus passive social media use; cognitive and social communication barriers to social media use; digital supports for social media use; and the need for policies and rehabilitation supports for social media use in individuals with ABI. The results indicate that more empirical research is needed to understand the uses, benefits and challenges, and facilitators and barriers of CMC and social media in adolescents with ABI. The next step of our research will be a phase 1 qualitative descriptive study using focus groups with key stakeholders (e.g., adolescents with ABI, parents/caregivers, rehabilitation professionals) is planned to identify themes around CMC and social media use in adolescents with ABI.
588 Contribution of white matter disruption to behavioral problems after concussion in children
Eman Nishata,b, Sonja Stojanovskia,b, Stephanie Ameisa,c, Shannon Scratcha,d, Anne Wheelera,b
aUniversity Of Toronto, Toronto, Canada, bHospital for Sick Children, Toronto, Canada, cCentre for Addiction and Mental Health, Toronto, Canada, dHolland Bloorview Kids Rehabilitation Hospital, Toronto, Canada
ABSTRACT
Background: Approximately one-quarter of children who have a concussion experience long-lasting behavioral problems including internalizing behaviors (e.g. aggression, inattention) and externalizing behaviors (e.g. anxiety, and depression) for more than 1-month after injury, with greater rates of persistent symptoms in females than males. White matter of the brain, made up of nerve fibers that are essential for communication between neural pathways, is highly susceptible to the stretching and shearing forces of concussions. Preexisting behavioral problems are strong risk factors for persistent behavioral problems after concussion. The challenge with identifying how a concussion causes long-lasting behavioral problems is the inability to dissociate the contribution of preexisting behavioral problems from injury to the vulnerable white matter of the brain due to a lack of behavioral and imaging data acquired before concussion.
Methods: This study examined a subset of children from the Adolescent Brain Cognitive Development (ABCD) Study, a large open-access developmental dataset providing a well-characterized longitudinal sample of children 9–10-years-old at baseline and 11–12-years-old at the two-year follow-up. 206 children experienced a concussion after study entry and had behavioral problems assessed with the Child Behavior Checklist. 111 of these children had MRI data available and white matter microstructure was characterized by restriction spectrum image modeling of diffusion MRI. Linear regression models were used to investigate the contribution of (1) pre-injury behavior and (2) pre- to post-injury change in white matter microstructure to post-injury internalizing and externalizing behavior scores.
Results: When controlling for pre-injury scores, post-injury internalizing scores were higher in female but not male children with concussion compared to children with no history of concussion (interaction: t = 1.9, p = 0.061; females t = 2.8, p = 0.0053; males t = 0.53 p = 0.60). Externalizing behavior scores were higher post-injury in both sexes (main effect: t = 2.2, p = 0.025). These results suggest that concussion elicits behavior problems above and beyond those that exist before the injury. Superficial white matter neurite density, a measure of structural integrity was reduced in children with concussion (t = −2.7, p = 0.0077). Lower levels of change in superficial white matter neurite density pre- to post-injury were associated with more internalizing problems in females but not males (interaction: t = 2.8, p = 0.0060; females t = −2.5, p = 0.018; males t = 1.2, p = 0.25). These results suggest that injury to the brain’s vulnerable white matter fibers may be a biological substrate for long-lasting internalizing behavioral problems after injury in females.
Conclusions: In this study pre-injury data were vital for dissociating the contribution of pre-injury factors to behavioral impairment after concussion which has been elusive to date. We have recently received funding for a 5-year study to identify adolescents with mental health concerns before injury and follow them prospectively to track and assess the impact of concussions on the brain and behavior longitudinally.
589 Creation of a disorders of consciousness education program for health care providers
Sheital Bavishia, Erin Montgomerya
aOhio State University Wexner Medical Center, Columbus, USA
ABSTRACT
Ohio State’s Disorder of Consciousness program is the only program in the state of Ohio. 10-year functional outcomes in DOC patients have been reported across all systems of care from the TBI-MS DOC special interest group. Patients with DOC are deemed to not be able to participate in 3 hours of therapy per day because of minimal ability to interact with the environment and follow commands. Therefore, they are usually transitioned to a skilled nursing facility with limited medical expertise of Brain Injury and DOC management. Studies have shown comprehensive inpatient rehabilitation programs are essential to assist patients with their emergence to consciousness.
Patients who do not receive specialized intensive rehabilitation early in their care often require extended stays within a long-term care environment and are at higher risk for developing secondary complications. All of this contributes to higher costs for overall care.
Provide education and training in order to establish collaborative, reciprocal relationships between Dodd Rehabilitation DOC team and local Subacute Rehabilitation Facility, Acute Care, and Long-Term Acute Care Hospital (LTACH) staff to improve continuity of care and outcomes in persons with, or who have emerged from, DOC.
Objectives:
● To provide high-quality training for staff in the community working with this population to promote comfort and optimal care, as well as to reduce overall burden, burnout, and risk of injury for staff
● To facilitate transition from Dodd to outside facilities for those that have gone through the DOC program and are not yet ready to transition home due to significant caregiver burden
● To facilitate appropriate assessment for and referral to Dodd’s DOC program from acute care hospitals, subacute rehabilitation facilities, and long-term acute care hospital settings
● To educate staff in the use of the Coma Recovery Scale-Revised. Because this test has the ability to measure very small changes in purposeful activity that other assessments cannot capture, it ensures the development of appropriate treatment plans and identifies those currently in an outside facility that could potentially benefit from transition to an inpatient rehab facility.
The program’s goal is to return individuals with DOC to their homes in their families’ care. This is not always achievable within the time-constraints of a typical two (2) week inpatient rehabilitation stay. As a result, we have extensive experience and have developed training for clinicians at the subacute rehabilitation facilities where our patients are referred. This is helpful for transition of care and continuation of skilled therapy services. Our long-range plan is to expand quality care for individuals in the DOC population by providing community education, specialized clinician training, and a centralized site for shared DOC resources within Ohio.
590 Investigating day-to-day experiences with conversational agents by users with traumatic brain injury
Yaxin Hua, Hajin Limb, Hailey L Johnsona, Josephine M. O’Shaughnessyc, Lyn Turkstrad, Melissa Duffe, Catalina Tomaf, Bilge Mutlua
aDepartment of Computer Sciences, University of Wisconsin – Madison, Madison, USA, bDepartment of Communication, Seoul National University, Seoul, Republic of Korea, cDepartment of Communication Sciences and Disorders, University of Wisconsin-Madison, Madison, USA, dSchool of Rehabilitation Science, McMaster University, Hamilton, Canada, eDepartment of Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, USA, fDepartment of Communication Arts, University of Wisconsin-Madison, Madison, USA
ABSTRACT
Traumatic brain injury (TBI) can cause cognitive, communication, and psychological deficits that profoundly limit independence in everyday life. These deficits can be evident even years post-injury, and can lead to negative outcomes such as social isolation and loss of employment. Conversational agents (CAs) are systems that engage in conversations with humans using written text or spoken communication. CAs can also serve as assistive technologies that can help individuals with disabilities, such as those with TBI, overcome barriers to independent living and improve their quality of life. This study aims to understand the day-to-day experiences of people with TBI using CAs. Participants were nine adults with moderate-severe TBI in the chronic stage (one year or more after injury). Participants were mailed Amazon Echo Dot CA devices, which they used for four weeks in their homes. We conducted one onboarding session and four weekly checkup interview sessions with each participant. Interview questions were grouped into four parts: (1) general usage and experiences with CA in the past week; (2) CA usage associated with post-TBI challenges; (3) feedback on the social chat feature; and (4) perception of the CA’s manner and personality. Participants reported diverse cognitive, communication, and sensorimotor symptoms and challenges related to TBI, as well as changes in their psychological states and ability to manage social situations. Findings revealed both participants’ social interactions and functional uses of CA related to their TBI experience. Social interactions include the use of social languages when talking with CAs, humanizing CAs as companions, humanizing CAs with questions, and self-disclosure of TBI experience. Functional uses of CAs aim to support cognitive, communication, and sensorimotor functioning in everyday life, including the use of CAs as memory aid (e.g., reminder, shopping list and timer), vocabulary aid, executive function assistance (e.g., reminder and routine), cognitive exercise (e.g., trivial games), and mental health support (e.g., meditation, calming tips and music). In addition, we observed usability challenges related to CA communication features such as timing and speed of turns, limited conversational content, and limited ability to sustain conversations. Participants reported privacy concerns of using CAs and worries about being overly dependent on the CA, while also expecting that the CA would be a personal system. The findings provided insights for designing CAs to meet the needs of people with TBI and suggested potential use of CAs in interactive journaling, companionship, and proactive task assistance. This study was part of the Social Building Blocks Online project, which aims to develop technology solutions to support online social participation by adults with TBI.
591 Assessment of near point convergence in victims of intimate partner violence entering shelters with suspected concussions
Kathleen Monahana, Hirsch Handmakerb, Sean Murphya
aStony Brook School of Social Welfare, Stony Brook, USA, bUniversity of Arizona College of Medicine-Phoenix, Phoenix, USA, cThe CACTIS Foundation, Scottsdale, USA
ABSTRACT
Intimate Partner Violence (IPV) occurs in 1 out of 3 women in the United States, underscoring a public health issue of epidemic proportion. Common mechanisms of brain injury sustained by IPV survivors include repeated blows to the head, face, and neck, resulting in single or repetitive Trauma Brain Injury (TBI) and/or nonfatal strangulation (NFS). In general, IPV victims do not seek medical attention highlighting lack of treatment and underreporting. Sequelae of TBI and NFS for this population include psychological (e.g. Posttraumatic Stress Disorder (PTSD), physical, cognitive, and neurological issues. In the evaluation of sports-related TBI/concussions, one of the most significant findings is a change in the Near Point Convergence (NPC). NPC is the distance from the spectacle plane to the point at which the eyes can no longer converge or turn in, ie. how well one can cross their eyes. The device we employ has several stimuli which serve as targets for the subject to watch and report when they see “double” and uses on-board microprocessor and ultrasonic technology to accurately measure the distance in centimeters from the spectacle plane of the subject to the visual stimulus of the instrument. NPC is an extremely important measurement in binocular vision. The normal measurements in individuals from 6 to 50 years old are ~6-8 cm, and are known to be affected in a very high percentage of persons sustaining a concussion. The measurement takes less than 2 minutes and can be downloaded to a mobile device, a surface pro or laptop. Our collaborative effort is undertaking a program that when victims of IPV are brought to a forensic nursing facility or shelter for interviewing or admission, trained staff will perform an NPC test, and share results with the victim. Victims will be offered the assistance of a social worker/advocate to follow up, and when the tests suggest that they have sustained a concussion, encourage them to seek further assessment and treatment to improve resumption of daily life and caring for their children, family, and themselves. It is well known that long after the physical signs of violence heal, the neurological and psychological symptoms remain. Up to now, conjecture surrounds the contribution of concussions to the cycle of domestic violence. To break the cycle of domestic violence, the collaborative partnership will focus on pillars of identification, research, clinical care, and education. Diagnostic data, management and treatment outcomes will be reviewed and analyzed by the partners to improve quality assurance, evaluate comparative effectiveness, and populate research databases, in manners compliant with HIPPA standards. The study results will provide evidence linking domestic violence, TBI, and co-morbidities, which will assist in personalizing treatment programs that we propose will empower participants to reenter society and the workforce.
592 Rehabilitation challenges with Kernohan-Woltman Notch phenomenon in traumatic brain injury – a case report
Cherry Junna
aUniversity of Washington, Seattle, USA
ABSTRACT
Setting: Inpatient rehabilitation unit
Case Description: 33-year-old female sustained a severe traumatic brain injury (TBI) after a fall. She was initially found unconscious for an unknown duration. Computed tomography (CT) of the head demonstrated a large right subdural hematoma with herniation of the temporal lobe over the tentorium with approximately 1.8 cm midline shift to the left with compression of the ventricles. When she emerged from a minimally conscious state, her physical examination showed right ipsilateral hemiplegia, right eye ptosis, and dysconjugate gaze with inferolaterally displaced right pupil. She was admitted to the inpatient rehabilitation unit without explanation of her ipsilateral hemiplegia. Subsequent magnetic resonance imaging (MRI) of the brain demonstrated increased T2/FLAIR signal in the left midbrain concerning for compressive injury in the setting of uncal herniation. With imaging finding consistent with the Kernohan-Woltman notch phenomenon (KWNP), she continued with therapies. At the time of discharge, the patient’s diplopia and dysconjugate gaze resolved. Her right hemiplegia improved, and she could transfer and ambulate short distances with contact guard assistance.
Assessment: The left contralateral hemispheric motor dysfunction is anticipated with right subdural hematoma. However, a patient can develop hemiparesis from an ipsilateral intracranial lesion, especially when there is a transtentorial herniation from an extensive midline shift and mass effect. Kernohan-Woltman notch phenomenon is an imaging finding resulting from the compression of the contralateral cerebral crus by the tentorium cerebelli1. It is a false localizing sign, which poses a challenge in rehabilitation for patients2. Prognostication for recovery becomes difficult without understanding the possible etiology of the weakness and can be prone to misdiagnosis2,3. There has been more recognition of false localizing signs such as KWNP which helps with understanding4. A review paper found that 67% of patients with KWNP had improvement in motor function, with 31% of patients attaining independence4.
Conclusion: False localizing signs can be underdiagnosed. Weakness with ipsilateral intracranial lesion must be investigated to determine the cause. Once diagnosed, a false localization sign helps the patient’s rehabilitation by avoiding misdiagnosis and providing accurate prognostication.
1. Hacking C, Ranschaert E. Kernohan phenomenon. In: Radiopaedia.Org. Radiopaedia.org; 2010. doi:10.53347/rID-10990
2. McKenna C, Fellus J, Barrett AM. False localizing signs in traumatic brain injury. Brain Inj. 2009;23(7–8):597–601. doi:10.1080/02699050902973921
3. Simonin A, Levivier M, Nistor S, Diserens K. Kernohan’s notch and misdiagnosis of disorders of consciousness. BMJ Case Rep. Published online February 17, 2014. doi:10.1136/bcr-2013-202094
4. Zhang CH, DeSouza RM, Kho JSB, Vundavalli S, Critchley G. Kernohan–Woltman notch phenomenon: a review article. Br J Neurosurg. 2017;31(2):159–166. doi:10.1080/02688697.2016.1211250
593 Mood-related symptom burden after concussion increases overall symptom response to cognitive exertion in adolescents
Dean Allena, Christopher Vaughana, Gerard Gioiaa
aChildren’s National Hospital, Rockville, USA
ABSTRACT
Objective: To investigate the effect post-injury mood symptoms have on symptom response to cognitive activity in adolescents following a concussion, compared to uninjured adolescents.
Participants and Methods: Two groups (uninjured (n = 49, mean age = 14.76 + 2.19, 58% female; and mTBI (n = 28; mean age = 14.14 + 2.17; 51% female) submitted exertional ratings on the 7-item (headache, fatigue, concentration, irritability, fogginess, light sensitivity, dizziness), 10-point Children’s Exertional Effects Rating Scale (ChEERS) pre- and post-exertion with intervening cognitive testing (15 minutes) and eye-tracking (15 minutes). The Exertional Effects Index (EEI) was calculated as a Post-Pre rating difference score, with negative scores set to zero. All participants completed the PostConcussion Symptom Inventory-Second Edition (PCSI-2), comprised of four clinical scales (physical, emotional, cognitive, and sleep/fatigue). Univariate analyses were conducted to compare the EEI between groups. Forward stepwise linear regression was applied to the mean ratings for each of the four PCSI-2 clinical scales to identify the key predictors of the 30-min EEI.
Results: Of the four PCSI-2 clinical scales, results of the linear regression analyses identify the Emotional scale to be the significant predictor of EEI for the mTBI group (B = 1.51, p < 0.01). Mean ratings on the PCSI Emotional scale were used to divide the sample into high- and low-mood-related symptom groups. The high mood-symptoms group (regardless of mTBI status) reported a higher pre-exertion rating than the low mood-symptoms group (m = 17.22 vs 8.21, p < 0.001). The mTBI group had a significantly higher EEI compared to the uninjured group (m = 5.29 vs 2.06, p < 0.01) at 30 minutes, and the mTBI children with higher mood-related symptoms exhibited marginally higher EEI ratings relative to the low mood mTBI group (m = 6.33 vs. 3.40, p < 0.11). Similarly, the uninjured children with high mood-related symptoms exhibited a significantly higher EEI compared to uninjured children with low mood-related symptoms (m = 3.62 vs 0.89, p < 0.04).
Conclusions: This study is an extension of Sady et al. (2018), examining exertional effects of seven symptoms in children post-concussion. The central findings suggest that patients reporting mood-related symptoms may be susceptible to greater perceived symptom exacerbation in response to cognitive activity. The results of the present study support Sady’s findings of greater EEI in mTBI adolescents compared to uninjured adolescents. These findings serve to assist clinicians in their management of adolescent patients recovering from concussion.
594 An international team approach to planning for the unexpected: providing brain injury rehabilitation in a crisis, war or disaster
Natalie Kalymona, Dee Sperryb, Mark Hollowayc, Howard Jacksond, Anna Markive
a365 Rehab, Toronto, Canada, bDeidre Sperry Speech Language Pathology, Hamilton, Canada, cHead First, Hawkhurst, United Kingdom, dTru, St. Helens, United Kingdom, eTRU, St. Helens, United Kingdom
ABSTRACT
In 2021, this International interdisciplinary team presented at IBIA on: The Development of Community Based Rehabilitation For People With TBI in Ukraine, and now this same team will present the new challenges faced by the outbreak of war in Ukraine. The International team that was created was the outcome of collaboration and networking at earlier IBIA conferences. This brain injury community allowed for the creation of a team with knowledge of the Ukrainian language and culture, together with expertise in the development of rehabilitation programming for dysexecutive syndrome. The team, consisting of a UK Neuropsychologist, UK Case Manager, Ukrainian physiotherapist, Ukrainian psychologist, Ukrainian rehabilitation coach, Canadian Speech-Language therapist, and Canadian Occupational therapist used telehealth to provide cross-cultural and cross-linguistic community-based rehabilitation in a country where this did not previously exist. The team navigated the first crisis of COVID and was able to continue to develop a program with purposeful and meaningful goals. Then when full-scale war broke out on February 20, 2022, the team mobilized and recognized that this was a “whatever it takes” situation. In times of crisis, people with executive dysfunction, anxiety, paranoia, and mobility issues continue to struggle and their functional problems may be magnified. With air-raid sirens, bombings, evacuation orders, the high cost of food, and a general environment of escalating fear and chaos, the need for unique approaches and strategies is imperative. In these situations, having intact frontal lobe functioning can mean the difference between life and death. This presentation will illustrate how our team managed to support our client in Ukraine and how his traumatic brain injury made an already stressful situation more complex. The realities of war created a rehabilitation environment nobody had a plan for. It was necessary for this interdisciplinary team to think creatively in order to support our client and his family to leave Ukraine and begin again in a new country. Developing structure for the dysexecutive client and infrastructure for the provision of rehabilitation, together with evacuation plans, presented a unique challenge. We will highlight the model of brain injury rehabilitation that was applicable semi-remotely in Ukraine and then even more so in the UK within a specialist service. The team was able to collaborate and implement strategies that allowed for a successful evacuation plan and reintegration into a new country and community. Through this experience, we have identified methods that support people with TBI in times of crisis.
595 Exploring the lived experiences of family caregivers of stroke patients in Africa: a scoping review of qualitative evidence
Mawukoenya Theresa Sedzroa,e, Laura Murraya,b, Anna Garnettc, Elysee Nouveta,d, Peace Fiadzomore, Keren Kankama
aHealth and Rehabilitation Sciences Program, Faculty of Health Sciences, University of Western Ontario, London, Canada, bSchool of Communication Sciences and Disorders, Faculty of Health Sciences, University of Western Ontario, London, Canada, cArthur Labatt Family School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, Canada, dSchool of Health Studies, Faculty of Health Sciences, University of Western Ontario, London, Canada, eDepartment of Speech, Language and Hearing Sciences, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana
ABSTRACT
Introduction: The burden of stroke is high in Africa and its health care systems are in need of a paradigm shift to overcome the many challenges being faced. The inadequate health care structures place major burden on patients and their family members, especially with regards to stroke care. Even the acute phases immediately following stroke are managed at home especially in the very low resourced areas on the continent, and most patients are usually supported by family caregivers in the long term. A stroke case of a family member therefore imposes care responsibility on some individuals within the family and this review seeks to explore such lived experiences.
Objective This scoping review sought to determine the size and scope of qualitative evidence that currently exists in relation to the lived experiences of family caregivers of stroke patients in Africa.
Inclusion Criteria: The review considered articles published in English up to May 2022 that reported primary, qualitative research involving family caregivers of stroke patients.
Methods DOAJ, Scopus, Embase, PsycINFO and MEDLINE (Ovid) databases were searched with keywords drawn from a selection of articles relating to the objective of the study. A general search using Google Scholar and hand search of reference lists of relevant articles identified additional literature. Included articles were appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research, and findings were extracted and summarized. The major review findings used a coding framework based on a priori themes developed against the review’s objective.
Results: Twenty-two articles were included in the review and the subsequent analysis. The extracted data outline key stroke outcomes that are commonly rehabilitated, the nature and outcomes of caregiving, and caregiving burdens and coping mechanisms. The intersectionality of socio-economic status, socio-political structures, and religious or traditional beliefs, attitudes and practices characterize etiology beliefs, treatment trajectories of stroke, and caregiving role assignment. Daily burdens of informal caregivers were largely driven by limited resources. Despite the challenges, caregivers developed coping strategies using spiritual or religious beliefs, optimism, and resilience, as well as through support networks in their communities and religious fraternities.
Conclusions: Findings suggest that caregiving for stroke survivors in Africa remains a continuing concern for researchers, health care professionals and policy makers. More specifically, informal caregivers need to be physically, economically, socially, and psychologically supported and integrated into the traditional health care system for a more comprehensive stroke care. Consequently, family caregivers’ health and well-being should be given more attention to consolidate their unrivaled contribution to stroke survivorship and outcomes in Africa. More collaborative studies incorporating the lived experiences of informal stroke care providers across the different sub-regions of Africa would offer more comprehensive insights on current needs and practices.
596 Return to play with R2Play: feasibility testing of an integrative and inclusive concussion assessment for youth
Danielle Duplessisa,b, Emily Lama,c, Josh Shorea,b, Hiba Al-Hakeema, Fanny Hotzéa, Ajmal Khana, Stephanie McFarlanda, Andrea Hicklinga,d, Michael Hutchisone,f,g, F. Virginia Wrighta,f, Nick Reedb,d, Elaine Biddissa,b, Shannon Scratcha,b,g
aBloorview Research Institute – Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada, bRehabilitation Sciences Institute – University of Toronto, Toronto, Canada, cInstitute of Biomedical Engineering – University of Toronto, Toronto, Canada, dDepartment of Occupational Science and Occupational Therapy – University of Toronto, Toronto, Canada, eFaculty of Kinesiology and Physical Education – University of Toronto, Toronto, Canada, fDepartment of Physical Therapy – University of Toronto, Toronto, Canada, gDepartment of Pediatrics – University of Toronto, Toronto, Canada
ABSTRACT
Background: Following concussion, traditional return-to-play (RtoP) protocols rely on a battery of single-domain assessments and self-reporting of symptoms to discern whether the injury has resolved. Yet, single-domain assessments may fail to detect symptoms and changes that are elicited by the cognitive, physical, and emotional multi-domain demands when an athlete returns to sport. We sought to bridge this gap by creating the R2Play system, which facilitates the implementation of a multi-domain RtoP assessment for youth athletes. We engaged in an iterative design process with key stakeholders including sports coaches and clinicians to develop a testable R2Play system prototype. As it stands now, the R2Play system is made up of two parts: a clinician tablet, and six tablet “buttons” that display numbers and letters. While completing R2Play, athletes run in a zig-zag pattern to complete the trail by pressing buttons in alpha-numeric order (1-A-2-B-3-C). Their performance across a series of trails of increasing difficulty is logged by the system and displayed on the clinician tablet.
Methods: To build on our rigorous design work, feasibility testing of the R2Play prototype was carried out with clinicians who were naïve to the system (n = 5) and healthy youth athletes (n = 10; age = 15.9 ± 4.23 yrs.; one wheelchair user). Athletes completed the R2Play protocol, which was administered by clinician participants and supervised by our research team. Following completion of the assessment, youth and clinician participants reviewed the R2Play results and provided feedback on the prototype through semi-structured interviews.
Results: Overall, R2Play operated smoothly, and only minor technical issues were documented. Clinicians rated the system’s usability as good-excellent (System Usability Scale = 81 ± 8.4), a promising result given the complexity of integrating the hardware, interface, and assessing an athlete. Testing took an average of 36 ± 6.5 mins to complete, and youth participants’ heart rates ranged between 69% to 75% of their age-predicted maximum. In support of R2Play’s face validity, youth noted that the system felt like playing sports, and clinicians remarked that the assessment produced richer data for decision-making than current RtoP protocols.
Conclusion: Initial feasibility results were promising, and future refinement will take place based on clinician and youth feedback. With further testing, R2Play may provide clinicians with a tool to assess athletes’ abilities to integrate skills across domains simultaneously. As a result of thorough problem definition early on and our user-centered design process, R2Play has a dramatically different look and feel than current concussion tools. Our work demonstrates that it is possible to create a sport-like cognitively and physically demanding assessment that is simple to administer and score with the help of low-cost technology. Further, we established that greater ecological validity can be achieved within the constraints of a clinic environment.
597 Participation in competitive employment after severe acquired brain injury in New South Wales, Australia: the VIP 2.0 multi-center implementation study
Grahame Simpsona,b,c, Philippa McRaec,d, Sally Homec,d, Jsephine Paasilac,d, Maysaa Daherc,d
aFaculty of Medicine and Health, University Of Sydney, Sydney, Australia, bJohn Walsh Center for Rehabilitation Research, Kolling Institute, Sydney, Australia, cBrain Injury Rehabilitation Research Group, Ingham Institute for Applied Medical Research, Sydney, Australia, dBrain Injury Rehabilitation Directorate, Agency for Clinical Innovation, NSW Health, Sydney, Australia
ABSTRACT
Background and Objective: Building effective pathways to employment for people with severe ABI is a priority in NSW. An initial controlled trial demonstrated the efficacy of the Vocational Intervention Program (VIP) in returning clients to competitive employment. The trial tested a partnership model, conducted among a subset of 6/12 community rehabilitation units from the NSW Brain Injury Rehabilitation Program (BIRP) who were linked with 3 vocational rehabilitation (VR) providers, compared to usual care among another 5/12 units. This paper reports outcomes from scaling up VIP in a state-wide implementation trial (VIP 2.0).
Methods: This pre-post implementation study partnered all 12 community rehabilitation units of the NSW BIRP with 20 VR providers to deliver two interventions: Fast Track (same employer) and New Track (new employer). Each BIRP unit was partnered with between 3 and 7 VR providers. Program employment outcomes were documented. Partnership quality between the BIRP units and VR providers was measured using the VicHealth Partnership Analysis Tool (PAT, 35 items, total score range 35–175) at two time points (baseline T0; project close T1, 3 years later).
Results: The 181 enrollments (47 Fast Track, 134 New Track) comprised 72% male, with a median age of 37 years. The majority sustained a TBI > 7 days PTA and the remainder severe ABI (e.g., stroke). Time post injury differed between the two interventions (median 8 months, Fast Track participants; median 18.5 months for New Track).
In total, 31 (66%) Fast Track enrollments were supported by VIP to return to work, 7 (15%) did not complete the program, and 6 (19%) who failed Fast Track then transferred to New Track. A range of outcomes were observed for the 134 New Track enrollments. Seventy-eight (58%) completed the program, of whom 44 (33%) secured paid work, 24 (18%) completed stepping stones to employment (work trial, n = 7; volunteer work, n = 12; training course, n = 5), and the remaining 10 (7%) were job-seeking. A further 54 (40%) withdrew prior to program completion, and 2 (1%) were assessed but commencement was delayed.
At baseline, 53 partnerships were established between the 20 VR providers and the 12 BIRP services, with 89% (47/53) of the partnerships still intact at project close. Partnership quality grew from baseline to project close as reported by both BIRP teams (T0 mean score 129, range 105–163; T1 mean 137, range 105–161) and VR providers (T0 mean score 131, range 105–161; T1 mean 141, range 102–173) with T0 scores falling into the PAT band ‘heading in the right direction’ and T1 scores as ‘genuine collaboration.’
Conclusions: The VIP 2.0 demonstrated the potential of a sustainable partnership model between health-based rehabilitation services and vocational rehabilitation providers in achieving a state-wide services system to promote vocational outcomes after severe ABI.
600 Stroke and post-stroke aphasia management in low- and middle-income African countries (Lmiac): a scoping review
Keren Kankama, Laura Murraya, Danielle Glistaa, Marie Savundranayagama, Mawukoenya Theresa Sedzroa, Selina Tetia
aUniversity Of Western Ontario, London, Canada
ABSTRACT
Stroke is a public health concern and one of the most common causes of morbidity and mortality worldwide. Although the severity of stroke has increased worldwide, high income countries have experienced a trend of declining stroke incidence, with increasing incidence in low- and middle-income countries (LMIC), particularly those in Africa (LMIAC). Approximately 85% of all strokes occur in LMIC, with stroke reported as the fourth leading cause of death in Africa. High incidence of stroke can result in high disability rates and consequently, negatively impact economic and social aspects of the individual, their family and the country at large. A major post-stroke disability is aphasia, which affects approximately 19% to 62% of stroke survivors. To improve on the quality of life of stroke survivors and their families, stroke and post-stroke aphasia management services are recommended. Considering the high incidence of stroke in LMIAC and the need for essential management services, the current scoping review examined research studies conducted in LMIAC to describe the available stroke and post-stroke aphasia management services, their accessibility, as well as facilitators and challenges of service delivery.
Methods. The scoping review, based on PRISMA-ScR guidelines, involved searching 10 electronic databases (e.g., MEDLINE, EMBASE) for empirical, peer-reviewed studies published in English between 2010 and 2022 using a combination of terms related to stroke and post-stroke aphasia management services in LMIAC. Searches yielded 2821 records; 1649 were screened following the removal of duplicates. Three reviewers screened the title, abstract, and full text of the articles, with 58 included for data extraction.
Results and Conclusions. The 58 included studies, 48 quantitative, 6 qualitative and 4 mixed methods, were conducted in 19 LMIAC. Only, four studies focused on post-stroke aphasia management services, three of which were clinical, focusing on cognitive behavior language therapy, or assessment or treatment of the complexity of impaired processing in bilingual anomia. There was heterogeneity among the types and amounts of stroke management services, with a predominant focus on pharmacological management (27 studies) and physiotherapy services (14 studies). Challenges reported regarding stroke and post-stroke aphasia management included language barriers between speech-language pathologists and individuals with post-stroke aphasia and lack of: (a) knowledge and awareness of stroke signs, (b) ambulance services leading to late hospital admissions, (c) access to diagnostic services, and (d) linguistically appropriate post-stroke aphasia resources. There remains a need to offer effective stroke and post-stroke aphasia management services to all individuals, as well as invest in post-stroke aphasia management research in LMIAC for a deeper understanding of current post-stroke aphasia care.
601 Filling a gap: a unique, evidence-based resource for college students with all-cause concussion
Conor Gormallya, Elizabeth Sandela,b, Kaori Hiranoa,c, Kira Kunzmana,c, Malayka Gormallya
aConcussion Alliance, USA, bParadigm, Walnut Creek, USA, cCarleton College, Northfield, USA
ABSTRACT
Sport-related mechanisms and contexts dominate the quantitative and qualitative study of collegiate concussions (mild TBI). For instance, the NCAA-DOD Care Consortium Study recruits NCAA student-athletes and cadets from military academies for their research. Non-sports-related concussion (nSRC) is more common than sports-related concussion (SRC) on college campuses and in the general population. College athletes and service academy cadets with nSRC have worse outcomes and more days lost to injury than those with SRC (Breck et al., 2019).
There is a clear need for non-sport-specific, mild TBI-specific resources for college students navigating social and academic life with mild brain injury. The impacts of a mild TBI on mental health, academics, and social life can be significant. Concussion Alliance has developed unique, evidence-based resources for students to navigate all aspects of college life while recovering from a concussion.
Concussion Alliance’s efforts stem from our collaborations with undergraduate students. We have educated 63 undergraduate interns from 7 colleges and universities via our Concussion Education & Advocacy Internship Program since 2019. Our interns, many of whom have personal experience with concussions, create unique website resources in partnership with leading professionals in the field.
Our College Students resource (ConcussionAlliance.org/college-students) includes three downloadable guides: a College Return-to-Learn Strategy, an Accommodations Guide for College Students, and a Concussion Guide for College Educators.
The Accommodations Guide guides students through requesting accommodations, providing examples of questions to ask and possible accommodations based on symptoms and environments (academic and non-academic). Our Return-to-Learn plan is, to our knowledge, novel in its focus on mild TBI among college students, separate from sport-related concussion. This plan is designed specifically for college students’ course schedules and provides a stepwise approach based on symptom tolerance of cognitive activity. The Concussion Guide for Educators includes current evidence-based information about concussion; explanations of the roles of educators, the Return-to-Learn plan, and campus resources; and offers a variety of adjustments that professors can incorporate to better support students with a concussion.
Concussion Alliance’s website resource page, Populations: College Students, includes unique resources to support college students based on insights from the organization’s undergraduate interns. A section on self-advocacy empowers students to advocate for themselves and their needs by providing language to use and education about their rights under the Americans with Disabilities Act. A section on social life equips students with strategies and information for navigating common college events and activities that may provoke symptoms, such as overstimulating environments and interactions with drugs and alcohol. A peer support section provides residential assistants (RAs), club leaders, and friends with guidance on including and supporting college students with concussion. Concussion Alliance plans to collaborate with colleges and universities to implement these resources on campuses around the United States.
602 Response to therapy and persistent deficits in traumatic brain injury complicated by cerebral infarction
Daniel McBridea, Jennifer Marwitza
aUniversity Of Alabama At Birmingham, Birmingham, USA
ABSTRACT
Patient was a 20-year-old female high school honors graduate with past medical history of bipolar disorder. She had recently undergone basic training with the Air Force but was on leave due to contracting COVID-19. She presented to our university hospital following a motor vehicle collision in which she was the restrained driver of a vehicle hit by an 18-wheeler. There was a positive loss of consciousness and prolonged extrication. Exam on arrival was notable for GCS 11 (E4V2M5) and traumatic injuries to the left head and face and bilateral upper extremities. Initial labs showed lactic acidosis, acute blood loss anemia, and leukocytosis. CT angiogram of the neck revealed traumatic complete occlusion of the proximal right ICA (grade 4 injury) and traumatic near-complete occlusion of the distal left ICA (grade 2 injury), both with distal reconstitution. MRI of the brain showed diffuse axonal injury and bilateral MCA watershed infarcts secondary to thromboembolism. Physical Medicine and Rehabilitation was consulted on the day after presentation, at which time the patient was requiring overall maximum assistance with ADLs, moderate assistance for ambulation. In addition, dysphagia required a liquid diet. The patient was admitted to inpatient rehabilitation on the third day after presentation, and rapidly progressed through her therapy goals. She discharged on the 10th day after presentation with no diet restrictions, having met all her Occupational Therapy goals and in Physical Therapy requiring supervision for stairs only. Her course was complicated by difficult-to-control pain, which resolved as she progressed, and persistent but mild memory and cognitive deficits requiring outpatient Speech Therapy follow-up. After discharge from rehabilitation, the patient was discharged from the Air Force due to brain injury, though 61 days after injury patient had returned to work at a retail store. At follow-up three months after presentation, patient was still suffering balance deficits with falls that resulted in the patient being placed on leave from her new job. At her six-month follow-up she was thought to have returned to cognitive baseline per her caregivers. At one-year follow-up, she had returned to work at her retail job full time without problems. At that time her PART (Participation Assessment with Recombined Tools-Objective) scores were above average compared to others with TBI at one year after injury. The patient also had higher than average FIM scores at one year post-injury. However, persistent mood and anxiety issues were reflected in her PHQ-9 and GAD-7 scores, as well as overall dissatisfaction with life. This case illustrates the uncommon co-occurrence of moderate traumatic brain injury accompanied by cerebral infarction, the importance of early rehabilitation in patient recovery, and some of the long-term complications that can complicate community reintegration.
605 Caregiver resilience: a longitudinal investigation
Jennifer Marwitza, Robert Pererab, Daniel Klyceb,c,d, Katherine Abbasib, Thomas Bergquiste, Dawn Neumannf,g, Stephanie Agtaraph, Jean Lengenfelderi, Flora Hammondf,g, Laura Dreera
aUniversity Of Alabama At Birmingham, Birmingham, USA, bVirginia Commonwealth University, Richmond, USA, cCentral Virginia VA Health Care System, Richmond, USA, dSheltering Arms Institute, Richmond, USA, eMayo Clinic, Rochester, USA, fIndiana University School of Medicine, Indianapolis, USA, gRehabilitation Hospital of Indiana, Indianapolis, USA, hCraig Hospital, Englewood, USA, iKessler Foundation Research Center, West Orange, USA
ABSTRACT
Objective: Examine the trajectory of resilience over the first two years post-injury among caregivers of individuals who have sustained a moderate-to-severe traumatic brain injury (TBI).
Method: Participants were adult caregivers (n = 200) and individuals with TBI who required inpatient rehabilitation at six TBI Model System sites. Measures were completed at 6, 12, and 24 months post-injury and included the Connor-Davidson Resilience Scale-10 (CD-RISC-10), Family Needs Questionnaire (FNQ), Zarit Burden Interview (ZBI), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7).
Results: A fixed effects model did not indicate statistically significant change, with a 0.04 increase in CD-RISC scores for a 1 month increase in time. Thus, if a caregiver had a lower resilience score at 6 months post-injury, their score remained relatively unchanged at 12 and 24 months post-injury. The same was true for caregivers with higher and average resilience scores. Overall, caregivers endorsed levels of personal resilience that were comparable to norms for community samples and slightly higher than groups under stress or with medical illness. Reports of burden associated with the caregiving role were relatively low, as was reported psychological distress.
Conclusions: Without intervention, resilience levels appear to be stable over the first two years post-injury. Further examination of resilience as a trait versus state is warranted.
606 Feasibility and acceptability of a personalized, healthy living telehealth-based intervention for community-dwelling survivors of moderate-severe traumatic brain injury (TBI): POWERS-TBI
Laura Dreera, Brooke Baileya, Molly Cox-Whitneya, Thomas Novacka, Robert Brunnera, Laura Rogersa, Payton Rackleya,c, Graycie Sotob, Yue Zhanga, Riis Wilsonc, Richard Kennedya
aUniversity Of Alabama At Birmingham, Birmingham, USA, bCenters for Disease Control & Prevention, Atlanta, USA, cSamford University, Birmingham, USA
ABSTRACT
Participation in healthy living is critical to improving health and overall well-being, along with preventing chronic health conditions. Unfortunately, sustaining a moderate-severe traumatic brain injury (TBI) can significantly compromise one’s health and ability to engage in healthy lifestyle behaviors. Lacking are available interventions that are integrative in nature and personalized to the unique health behaviors and barriers experienced by survivors of TBI. Existing programs for these individuals focus predominantly on improving one or two lifestyle behaviors. We addressed this gap by evaluating the impact of a personalized, healthy living telehealth-based intervention for community-dwelling survivors of a moderate-severe TBI.
Methods: As part of this ongoing study, N = 17 survivors of a moderate-severe TBI completed the Client Satisfaction Questionnaire (CSQ) immediately after participating in a 6-month, telehealth-based healthy living intervention. The intervention was personalized to participants’ unique health goals of interest (e.g., physical activity; mental health/stress management; spirituality/purpose and meaning; social health; mental activity and stimulation; leisure; dietary intake/nutrition; sleep; substance use, etc.). Feasibility and acceptability were assessed using the CSQ, along with qualitative data to understand rationale for ratings.
Results: Overall acceptability was high for the program in terms of satisfaction ratings for: the quality of the health coaching calls received (66.7% “excellent,” 33.3% “good”); getting the kind of information wanted with regards to health goals (50.0% “yes, definitely”; 38.9% “yes, generally”; only 11.1% “no not really”); amount of help received during the weekly health coaching calls (61.1% “very satisfied”; 33.3% “mostly satisfied”; only 5.6% “indifferent or mildly dissatisfied”; the health coaching calls helped you deal more effectively with your health (61.1% “yes, they helped a great deal”; 38.9% “yes, they helped somewhat”). Feasibility and acceptability were also supported given the satisfaction with the length of the program (83.3% “just about right”; 5.6% “too short”; only 11.1% “too long”) and the majority endorsed they would recommend the program to a friend if they had a TBI (94% “yes, definitely”; 5.6% “yes, generally”). The majority of the participants (77.8%) endorsed a preference for the delivery of the program via both coaching calls and with the use of the health platform; only 22.2% reported health coaching calls alone and 0.0% endorsed health platform alone. The majority recommended rehabilitation providers refer patients to this intervention (83.3% “yes, definitely”; 16.7% “yes, generally”). When asked about how soon after injury they would recommend rehabilitation providers refer patients, responses were mixed: 33.3% at 12-months post-injury, 33.3% at 6-months post-injury, 22.2% at “discharge from inpatient rehabilitation,” 11.1% “during inpatient rehabilitation.”
Conclusions: POWERS-TBI healthy lifestyle intervention appears to show feasibility and acceptability among community survivors of moderate-severe TBI. This presentation will also include detailed qualitative data regarding the rationale for ratings and highlight the breadth of health goals endorsed.
607 Translating functional measures: developing a crosswalk between standardized cross-setting assessment and site-specific assessment
Chih-ying Lia, Trudy Mallinsonb
aUniversity Of Texas Medical Branch, Galveston, USA, bThe George Washington University, Washington, USA
ABSTRACT
Background: The Centers for Medicare and Medicaid Services (CMS) has developed and implemented the Standardized Patient Assessment Data Elements or SPADE across post-acute care (PAC) settings. Standardized functional items, known as Section GG of SPADE, will replace current site-specific functional items used at inpatient rehabilitation facilities, skilled nursing facilities and home health care agencies.
Objective: This study demonstrated using Rasch analysis for the creation of a crosswalk in self-care items between the standardized functional Section GG and the site-specific Functional Independence Measure (FIM®) reported by the inpatient rehabilitation clinicians.
Methods: We used 2019 CMS administrative claims to create the crosswalk for patients living with stroke (N = 10,140) using Rasch analysis, after applying the developed algorithm to include only consistent responses between Section GG and FIM to reduce coding errors. We then developed a self-care item bank to co-calibrate seven Section GG items and six FIM items. We then co-calibrated Section GG and FIM self-care items based on the generated Rasch-Andrich threshold and item step thresholds from the item bank. We also calculated Pearson Correlation Coefficients of the total scores between Section GG and FIM items.
Results: The combined Section GG-FIM item bank showed good internal consistency (Cronbach alpha = 0.96), met three rating scale diagnostic criteria. Rasch principal component analysis showed the item bank explained 75.9% (> 40% cutoff) of the total raw variance, and 8 of the 13 items showing acceptable fit statistics. The item bank covered the range of theta from −2.60 to 1.57 (item), with person strata of 5.4. The Section GG and FIM raw scores correlated at 0.95.
Conclusion: Our findings suggested the self-care function item bank constructed from Section GG and FIM measured a single construct with overall acceptable item-level psychometric properties, suggesting the item bank can be used as a source for developing the crosswalk to translate functional scores between standardized Section GG and site-specific FIM functional items.
608 Sex differences of violence related etiology in the traumatic brain injury model systems dataset
Librada Callendera, Simon Drivera, Rosemary Dubiela
aBaylor Scott and White Institute For Rehabilitation, Duncanville, USA
ABSTRACT
Background: The intersection of violence, traumatic brain injury (TBI), and sex is an important but understudied topic. The proportion of violence-related etiology (VRE) is greater among men in prior literature, but the context in which VRE occurs differs between sexes (e.g., women more likely to sustain VRE TBI as a result of intimate partner violence (IPV), whereas men due to firearms or assault). The objective of this study is to characterize sex differences in pre-injury characteristics and early post-injury clinical characteristics among individuals with and without VRE TBI.
Methods: Analysis of the TBIMS database was conducted from 10/01/1990-12/31/2019. The main outcome measure for the project was VRE TBI, identified using primary and secondary ICD-9/ICD-10 E-codes and cause of injury category. Demographic (age, race/ethnicity, marital status, education, employment, payer), pre-injury, and clinical characteristics (post-traumatic amnesia, Disability Rating Scale, Functional Independence Measure) were stratified by women and men with and without VRE, and statistical testing was conducted to compare the four groups.
Results: During the period examined, 18,135 patients were enrolled, with 4,729 women and 13,406 men. Among those identified with VRE codes, 267 (5.6%) were women and 1,696 (12.7%) men. The most common ICD codes for women were E965.4- Assault by firearm (16.5%), E968.2- Assault by striking by blunt/thrown object (13.9%), and E968.9- Assault by unspecified means (13.9%). The most common VRE codes for men were E968.2- Assault by striking by blunt/thrown object (26%), E968.9- Assault by unspecified means (17.3%), and E960.0- Unarmed fight/brawl (13.9%). Significant differences (p < 0.05) were identified when comparing women with and without VRE, men with and without VRE, and women and men with VRE. Women with VRE were younger than women without VRE, but older than men with VRE. Men and women with VRE compared to men and women without VRE were overall less white, more single, less married, less educated, more unemployed, lower proportions of private insurance, lower proportion of living with a spouse/significant other at the time of injury, and endorsed more mental health problems. Women with VRE had more mental health history than men with VRE and women with VRE had more psychiatric hospitalizations than women without VRE. Men with VRE had a higher proportion of smoking, heavy drinking, and prior felony convictions than men without VRE and women with VRE.
Discussion: Sex differences exist among individuals with VRE TBI. Outcomes data (e.g., behavioral and social outcomes) should be examined in future investigations stratified by sex. Standardized protocols do not currently exist to assess and document VRE TBI or domestic/IPV in the clinical setting, but these are important to implement to understand accurate prevalence estimates which are essential for proper resource allocation, improved detection, prevention and management of VRE TBI.
609 Exploring functional connectivity among adults with persistent post-concussion syndrome using functional near infrared spectroscopy
Sané du Plessisa,b, Ibukunoluwa Onia,b,c, Andrew Lapointeb,c, Christina Campbella, Alison Wilsona, Kaiden Jobina,b, Jeff Dunna,b,c, Chantel Deberta,b
aDepartment of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada, bHotchkiss Brain Institute, Calgary, Canada, cDepartment of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
ABSTRACT
Approximately one third of all concussions lead to persistent post concussion syndrome (PPCS). Functional near infrared spectroscopy (fNIRS) is a noninvasive imaging technique that measures the differences in the absorption of local oxy- and deoxyhemoglobin in the brain. The changes in cerebral tissue oxygenation are then used to monitor brain activity. fNIRS has demonstrated comparability to fMRI for reliably detecting changes in cerebral vascular reactivity and may provide insight into the pathophysiology of PPCS. The aim of this study was to compare the hemodynamic response of participants with PPCS to symptom burden using fNIRS in frontal and motor brain regions. Thirty-four adults (18–65) with PPCS (>3 months – 5 years) were asked to complete a series of clinical questionnaires including the Rivermead Post-Concussion Symptom Questionnaire (RPQ) to assess symptom burden and complete a resting task, motor task, and working memory (n-back) task during fNIRS assessments. Demographic information including age, sex, education level and employment status, and participant characteristics including concussion history, past medical history, medication use, and family medical history were also collected. A multiple regression analysis was conducted to assess the relationship between functional connectivity measures and symptom severity scores after consideration for age, sex, and time since injury. RPQ scores did not predict functional connectivity measures for oxy- (β = 0.09, P = 0.96) or deoxyhemoglobin (β = 0.31, P = 0.08) between the right and left dorsolateral prefrontal cortex (DLPFC) during the n-back task. However, increased deoxyhemoglobin functional connectivity measures between the left and right DLPFC during the n-back task were correlated with higher depression scores (β = 0.44, P < 0.05), anxiety scores (β = 0.54, P < 0.05), somatoform symptom scores (β = 0.43, P < 0.05), and post-traumatic stress scores (β = 0.43, P < 0.05). Furthermore, the relationship between n-back fNIRS connectivity values and RPQ was further explored by analyzing the relationship between specific symptoms and fNIRS outcomes. Several RPQ items were correlated with task-evoked deoxyhemoglobin functional connectivity scores between the left and right DLPFC including “feeling depressed or tearful” (β = 0.41, P < 0.05), “poor memory or forgetting” (β = 0.34, P < 0.05), and “difficulty concentrating” (β = 0.34, P < 0.05). The preliminary data and results from this study may contribute to a better understanding of brain function and specific symptoms in patients with PPCS.
611 Mild traumatic brain injury involves accelerated rates of regional brain aging
Alexander Mahera, Roy Massetta, Nikhil Chaudharia, Anar Amgalana, Nahian Chowdhurya, Maheen Adamsonb, Andrei Irimiaa
aUniversity Of Southern California, Los Angeles, USA, bStanford University, Stanford, USA
ABSTRACT
Regional brain volumes typically decrease after traumatic brain injury (TBI) but the rates of such decreases are unknown. We quantify these rates cross-sectionally in 113 persons with recent mild TBI (mTBI), whom we compare against 3418 healthy controls (HCs). Regional gray matter (GM) volumes were extracted from magnetic resonance images (MRIs). Linear regression yielded regional brain ages and annualized average rates of regional GM volume loss. Results were compared across groups after accounting for sex and intracranial volume. The adjusted rate β_HC of regional volume loss was quantified as a percentage of volume decrease per year (%/y). In mTBI participants, the linear models generated for the HC participants were used to compute regional brain ages. In HCs, the steepest rates were recorded, bilaterally, in the nucleus accumbens (β ± SE (β) = −0.187%/y ± 0.017%/y), amygdala (β ± SE (β) = −0.100%/y ± 0.011%/y), lateral orbital sulcus (β ± SE (β) = −0.096%/y ± 0.018%/y), posterior transverse collateral sulcus (β ± SE (β) = −0.091%/y ± 0.017%/y), and the collateral and lingual sulcus (β ± SE (β) = −0.091%/y ± 0.011%/y). In participants with mTBI, ~80% of gyri and sulci had significantly steeper rates of annual volume loss than in HCs. The strongest dependences of regional volume on age were observed in the nucleus accumbens (β ± SE (β) = −0.578%/y ± 0.072%/y), middle temporal gyrus (β ± SE (β) = 0.451%/y ± 0.086%/y), the posterior transverse collateral sulcus (β ± SE (β) = 0.386%/y ± 0.089%/y), inferior temporal sulcus (β ± SE (β) = 0.368%/y ± 0.073%/y), and the thalamus (β ± SE (β) = 0.367%/y ± 0.053%/y). The largest differences between HCs and mTBI participants involved the cerebellum (β ratio (TBI/HC) = 7.0, z = −4.60, p = 1.19 × 10–4, power > 99%), thalamus (β ratio (TBI/HC) = 4.8, z = −5.37, p = 6.40 × 10–6, power > 99%), and nucleus accumbens (β ratio (TBI/HC) = 3.09, z = −5.26, p = 5.82 × 10–6, power > 99%). Some regional brain ages were significantly older than expected, notably in the posterior-dorsal cingulate gyrus (2.4 y), middle frontal gyrus (2.3 y), middle temporal gyrus (2.2 y), orbital sulci (1.8 y), and superior frontal gyrus (1.7 y). In conclusion, mTBI involves significantly steeper regional GM volume loss rates than in HCs, reflecting older-than-expected regional brain ages.
612 Patient perspectives – feedback on the physiotherapy gym experience in a national referral center for neurosurgery, neurology and thrombectomy
Isabelle Corridana, Sarah Burkea
aBeaumont Hospital, Beaumont, Ireland
ABSTRACT
Background: The physiotherapy gym is a key part of the physiotherapy department and important in a patient’s neuro-rehabilitation journey. Patient experience surveys have become an important channel for patient participation in identifying shortcomings in healthcare services and co-creating solutions to some of the identified challenges (HIQA, 2019).
Aims and Objectives: The objectives of the study were to obtain feedback from inpatients on their experience in the physiotherapy gym with focus on the following key areas:
The gym environment
Patient dignity and respect
Physiotherapist communication
Identifying positive aspects of the physiotherapy gym experience
Identifying areas for future development
Methodology: A draft survey was designed based on the National Inpatient Experience Survey. The survey was reviewed by physiotherapy service leads and management and amendments agreed upon. Inpatients with a GCS of 15/15 who attended the physiotherapy gym between 23/05/2022 and 17/06/2022 were invited to participate in the survey. Twenty participants were recruited. The survey consisted of structured ‘tick box’ questions with space for patients to contribute comments. Two principal investigators analyzed the response data. A thematic analysis of qualitative responses was completed using the methods outlined by Braun and Clarke (2016). The responses to the ‘tick box’ questions were scored using methods equivalent to those used in the National Inpatient Experience Survey.
Results & Discussion: Eighty percent of patients reported that their overall physiotherapy gym experience was ‘excellent.’ Physiotherapists were scored 10/10 for treating gym users with dignity and respect, however when asked if participants felt prepared for their gym session, the average score was 7.9/10. Three major themes were identified when analyzing positive aspects of the physiotherapy gym experience – the therapeutic relationship, empowerment, and patient-centered care. Major themes identified while analyzing areas for development were environment, communication, and gym therapy frequency.
Future Recommendations: Recommendations to enhance the physiotherapy gym experience include improved communication from the therapist regarding scheduling of physiotherapy gym sessions and therapy frequency. Responses to the survey were collected by physiotherapy staff, as such, potential bias toward more positive feedback should be considered a limitation of this study. Future evaluations of the physiotherapy gym experience could include involvement of nonaffiliated investigators in the recruitment of participants and survey collection phases.
613 What is the role of SARM1 in axonal connectivity and degeneration?
Alison Cantya,b, Ensieh Izadib, William Bennettb, Maneesh Kuruvillab, Anna Kingb
aGlobal Brain Health Institute, Trinity College Dublin, Dublin, Ireland, bWicking Dementia Research and Education Center, University of Tasmania, Hobart, Australia
ABSTRACT
Axons are long, fine processes that carry cellular materials and electrical information around the nervous system and the body, often at considerable distances. Axons are particularly vulnerable to injury and degeneration through mechanisms such as inflammation, twisting, shearing, rapid deacceleration and even transection. Axon degeneration is a hallmark of traumatic brain injury and neurodegenerative disease, and is a significant cause of death and disability worldwide. Sterile Alpha and TIR motif-containing protein 1 (SARM1) is emerging as a key player in modulating axon degeneration. Following an injury, SARM1 is activated, which results in rapid depletion of NAD+ and energy stores in the axon, which accompanies signaling cascades that lead to axon degeneration. SARM1 activation appears to hasten the process of axonal degeneration, but does it have any role in maintaining axonal connectivity in the cerebral cortex in the absence of injury?
Through an implanted cranial window overlying the cortex of the Thy1-GFP-M mouse model, we can directly visualize excitatory axons in the upper layers of the intact brain, and we crossed these mice to Sarm1KO null mutants. During initial imaging sessions, we identified long synapse-rich axons in the primary motor cortex. Axons were classified as being rich in terminaux boutons, en passant boutons, or both. For each axon subpopulation, we compared the overall axonal morphology, synaptic density, and synaptic turnover in the presence and absence of SARM1 (n = 19 axons). Each axon was imaged at least four times at 48-hour intervals to determine the synaptic density (synapses/unit length) and turnover (a measure of how dynamic the synapses are). Preliminary analysis indicates that axon morphology, synaptic density and turnover are comparable in the young adult brain in the presence or absence of SARM1. Following this, we used the imaging laser to create discrete microlesions along the axon shaft, to monitor the axonal response to injury in real time. Analysis of the time and rate of onset of axonal degeneration in the presence and absence of SARM1 is underway.
614 Perivascular space volume in youth soccer players
Tim L. T. * Wieganda,b,c, Leonard B. * Junga,b,c, Elena M. Bonkea,b,c,d, Noah B. Junga, Hanno Nitzpona, Lara Pankatza,b,c, Eukyung Yhange, Farshid Sepehrbandf, David Kaufmanna,g, Stian Bahr Sandmoh,i, Alberto De Lucaj, Caroline Seerk, Marc Muehlmannl, Martin Centem, Elisabeth Kaufmanna,n, Michaela V. Bonferto, Florian Heineno, Sylvain Bouixc,p, Yogesh Rathic,q, Alexander P. Linc,r,s, Martha E. Shentonc,r,t, Yorghos Tripodise,u, Nir Sochenv, Jolien Gooijersk, Roald Bahrh, Peter Filipcikm, Alexander Leemansj, Stephan P. Swinnenk, Ofer Pasternakc,r, Inga K. Koertea,b,c,d,t
acBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-Universität, Munich, Bavaria, Germany, bNICUM (NeuroImaging Core Unit Munich), Munich, Germany, cPsychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, dGraduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität, Munich, Germany, eDepartment of Biostatistics, Boston University School of Public Health, Boston, MA, USA, fStevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA, gDepartment of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany, hOslo Sports Trauma Research Center, Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway, iDivision of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway, jImage Sciences Institute, Division Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands, kMovement Control and Neuroplasticity Research Group, Department of Movement Sciences, KU Leuven, Leuven (3000), Belgium, lDepartment of Radiology, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany, mInstitute of Neuroimmunology, Slovak Academy of Sciences, Bratislava, Slovakia, nDepartment of Neurology, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany, oDepartment of Pediatric Neurology and Developmental Medicine, Dr. von Hauner Children’s Hospital, University Hospital, Ludwig-Maximilians-Universität, Munich, Germany, pDépartement de génie logiciel et TI, École de Technologie Supérieure, Université du Québec, Montreal, Québec, Canada, qCenter for Morphometric Analysis, Department of Psychiatry and Neurology, A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, rDepartment of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, sCenter for Clinical Spectroscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, tDepartment of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, uAlzheimer’s Disease and CTE Centers, Boston University School of Medicine, Boston, MA, USA, vDepartment of Mathematics, Tel-Aviv University, Tel-Aviv, Israel
ABSTRACT
Introduction: Repetitive head impacts (RHI) in soccer have been associated with increased risk for neurodegenerative disorders later in life. However, the underlying pathophysiology is largely unknown. Impaired glymphatic brain clearance has been proposed as a mechanism underlying post-traumatic neurodegeneration. Perivascular space (PVS) volume, measured using magnetic resonance imaging (MRI) is purported to reflect glymphatic function. Enlarged PVS volume has been associated with cognitive impairment in older adults. However, whether PVS volume is associated with cognitive function in youth athletes is unknown. Further, whether exposure to RHI while playing soccer is associated with greater PVS volume remains to be elucidated.
Methods: We studied 74 competitive soccer players and 37 non-contact sport athletes who participated in the REPIMPACT study. All participants were male and between 13–16 years. Participants were studied before the beginning of a play season at three sites (Germany, Norway, Belgium). We used T1-weighted MRI to obtain subject-specific white matter (WM) PVS volume. Following quality assessment and corrections of PVS maps, PVS volume was adjusted for individual WM volume, and log-transformed. Cognitive function was assessed using the computerized testing battery Cogstate and z-transformed summary scores of executive function, speed, and memory were calculated. Exposure to RHI was estimated based on self-reported years of playing soccer. A linear mixed effects model was used to analyze group differences in PVS volume between soccer players and controls (covariates: site, age). Associations between cognitive function and PVS volume in the entire sample was analyzed using linear regressions (covariates: group, site, age). An association between PVS volume and exposure to RHI in soccer was analyzed using a linear regression (covariates: site, age). Results were corrected for multiple comparisons using Benjamini-Hochberg’s procedure.
Results: There were no differences in PVS volume between soccer players and non-contact sport athletes (est. = 0.018; p = 0.688). There was an association between larger PVS volume and lower memory z-scores (β = −0.905; p = 0.024) in the entire sample. There were no associations between PVS volume and speed (β = −0.344; p = 0.328) or executive function (β = −0.314; p = 0.328). Within the soccer group, more years of playing soccer (mean = 9.74 years; SD = 1.37 years) were associated with larger PVS volume (β = 0.041; p = 0.024).
Discussion: In youth athletes, larger PVS volume was associated with lower performance on memory tests. While PVS volume did not differ between youth soccer players and non-contact sport athletes, within the soccer group, more years of play were associated with larger PVS volume. This may potentially suggest a link between years of playing soccer (which likely includes exposure to RHI) and larger PVS volume, an MRI-based measure of altered glymphatic function.
Wiegand TLT and Jung LB contributed equally.
615 Diffusion alterations at the gray matter-white matter intersection are associated with traumatic encephalopathy syndrome
Luisa S. * Schuhmachera,b, Tim L. T. * Wieganda,b,c, Leonard B. Junga,b,c, Lara Pankatza,b,c, Hector Arciniegac, Fatima Tuz-Zahrad, Sylvain Bouixc,e, Michael L. Aloscof, Yorghos Tripodisd,f, Michael Colemanc, Alexander P. Linc,g,h, Jeffrey L. Cummingsi, Eric M. Reimanj, Robert A. Sternf,k, Martha E. Shentonc,h,l, Inga K. Koertea,b,c,l,m
acBRAIN, Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwigs-Maximilians-Universität, Munich, Germany, bNICUM (NeuroImaging Core Unit Munich), Munich, Germany, cPsychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, dDepartment of Biostatistics, Boston University School of Public Health, Boston, MA, USA, eDepartment of Software Engineering and Information Technology, École de technologie supérieure, Montreal, QC, Canada, fAlzheimer’s Disease and CTE Center, Boston University School of Medicine, Boston, MA, USA, gCenter for Clinical Spectroscopy, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, hDepartment of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA, iChambers-Grundy Center for Transformative Neuroscience, Department of Brain Health, University of Nevada School of Integrated Health Sciences, NV, USA, jBanner Alzheimer’s Institute, University of Arizona, Arizona State University, Translational Genomics Research Institute, and Arizona Alzheimer’s Consortium, Phoenix, AZ, USA, kDepartments of Neurology, Neurosurgery, and Anatomy & Neurobiology, Boston, University School of Medicine, Boston, MA, USA, lDepartment of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, mGraduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität, Munich, Germany
ABSTRACT
Introduction: Chronic Traumatic Encephalopathy (CTE) is a neurodegenerative disease associated with tau deposition in the depth of cortical sulci. While CTE can only be diagnosed postmortem, traumatic encephalopathy syndrome (TES) is the clinical disorder associated with CTE. American football players are exposed to repetitive head impacts (RHI), a risk factor for developing CTE. Computer simulations of a player collision in American football showed highest strain in the depth of cortical sulci along the gray matter-white matter intersection (GM-WM intersection). This is also the location where tau depositions in CTE typically occur first. Whether the microstructure at the GM-WM intersection is associated with TES remains unknown.
Methods: We studied 166 male symptomatic former American football players aged 49–65 years from the DIAGNOSE-CTE Research Study. Diffusion tensor imaging and T1-weighted magnetic resonance imaging were used to extract free-water corrected FA (FAT) at the GM-WM intersection of the whole brain. TES was assessed using the 2021 National Institute of Neurological Disorders and Stroke Consensus (NINDS) diagnostic criteria. More specifically, we used diagnoses of TES, TES with cognitive impairment, TES with neurobehavioral dysregulation, level of certainty for CTE pathology, and levels of dementia. We used a generalized least squares model to analyze associations between FAT at the GM-WM intersection of the whole brain, cerebral sulci, and cerebral gyri with TES diagnoses as well as levels of certainty for CTE pathology and dementia. All analyses included age, BMI, race, years of education, imaging site, and binary ApoE4 carrier status as covariates. Results were corrected for multiple comparisons using Benjamini-Hochberg’s procedure.
Results: Higher FAT at the GM-WM intersection was associated with the diagnosis of TES (mean: 0.004, p: 0.032) and TES with neurobehavioral dysregulation (mean: 0.005, p: 0.001). Moreover, higher FAT was associated with a higher level of certainty for CTE pathology (mean: 0.006, p: 0.015) and a higher level of dementia (Mean: 0.004, p: 0.043). Associations between FAT at the GM-WM intersection and TES with cognitive impairment did not reach statistical significance (mean: 0.004 p: 0.081).
Conclusion: Our results suggest that microstructural alterations at the GM-WM intersection, a brain region particularly susceptible to mechanical strain, are associated with characteristics of TES in former American football players. Higher FAT at the GM-WM intersection may be due to higher cellularity (e.g., microglia) associated with CTE pathology.
Schuhmacher LS and Wiegand TLT contributed equally.
616 The clinical utility of candidate blood biomarkers representing inflammation and cns injury in the assessment of post-concussion syndrome at 3 months
Gerard Clarkea, Toril Skandsena, Viktoriia Chabanb, Turid Follestada, Anne Vika, Cathrine Einarsena, Henrik Zetterbergc, Kaj Blennowc, Tom Mollnesb, Søren Pischkeb
aNTNU, Trondheim, Norway, bUniversity of Oslo, Oslo, Norway, cUniversity of Gothenburg, Gothenburg, Sweden
ABSTRACT
The aim of our study was to determine the best combination of clinical factors in predicting post-concussion syndrome (PCS) – assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI) – at 3 months following mild TBI. Patients with mTBI (16–60 years) were defined as having a Glasgow Coma Scale (GCS) score between 13–15, loss of consciousness (LOC) < 30 min and post-traumatic amnesia (PTA) < 24 hours. Clinical/demographic factors investigated were age, sex, GCS, LOC, PTA, traumatic intracranial finding on MRI (within 72 h), other somatic injuries, plasma-derived proteins associated with central nervous system (CNS) damage (Tau, GFAP and NFL) and markers of inflammation (IFN, IL-8, Eotaxin, MIP-1, MCP-1, IP-10, IL-17A, IL-9, TNF, FGF-basic PDGF and IL-1ra). Blood was drawn between 24–72 hours, at 2 weeks, and 3 months after injury. The discriminatory value (AUC analysis) of each individual blood biomarker predictor was at chance level. For each timepoint, combining blood biomarkers (using a best-subsets feature selection method to select the best combination of markers) also did not discriminate PCS at clinically relevant levels (AUCs 0.66–0.71). A best-subsets model including all candidate biomarkers, injury-related characteristics and demographic variables was also computed to predict PCS. At 24–72 hours, the blood biomarkers included in the full model were TNF, IL-9, IL-17A and IL-8. At 2 weeks, a combination of PDGF, IL-8 and IFN, best predicted PCS, while at 3 months, a combination of PDGF, FGF-basic and IFN were included in the model. The baseline clinical injuries predicting PCS in all models were being a woman, longer PTA, presence of traumatic intracranial findings on MRI, and lower GCS. In conclusion, our study shows that blood biomarker levels in acute, subacute and chronic phases of MTBI were associated with PCS, but these biomarkers did not have the clinical specificity/sensitivity to reliably discriminate PCS.
617 Age, sex and extracranial injuries as confounders of blood biomarkers analysis in mild traumatic brain injury
Katja Malmia, Jussi Postia,b, Olli Tenovuob,c, Kaj Blennowk,l, Iftakher Hossaina,b,c,d, Peter Hutchinsond, Henna-Riikka Maanpääa,b,c, David Menong, Virginia Newcombeg, Jean-Charles Sanchezh, Riikka Takalae, Jussi Tallusb,c,i, Mark van Gilsf, Henrik Zetterbergi,j,k,l,m, Mehrbod Mohammadianb,c
aNeurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland, bTurku Brain Injury Center, Turku University Hospital, Turku, Finland, cDepartment of Clinical Neurosciences, University of Turku, Turku, Finland, dDepartment of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom, ePerioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland, fFaculty of Medicine and Health Technology, Tampere University, Tampere, Finland, gDivision of Anesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom, hDepartment of Specialties of Internal Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland, iDepartment of Radiology, University of Turku and Turku University Hospital, Turku, Finland, jInstitute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden, kClinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden, lDepartment of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom, mUK Dementia Research Institute at UCL, University College London, London, United Kingdom, nHong Kong Center for Neurodegenerative Diseases, Hong Kong, China
ABSTRACT
Background: Blood-based biomarkers have shown promising results as outcome predictors and resource-efficient complementary diagnostic tools for traumatic brain injury (TBI). In the search for the optimal biomarkers for TBI diagnostics and outcome prediction, many important questions remain to be answered. There is limited research data about how confounding factors such as age, sex, previous medical conditions, or co-existing extracranial injuries affect brain-enriched biomarker levels. Research into these issues is necessary so that biomarkers can be used clinically in the most common patient populations in the future.
Methods: To study age, sex and extracranial injuries as confounders of TBI biomarkers we used a previously characterized cohort. Patients with i) blood levels of Amyloid B40 (AB40), Amyloid B42 (AB42), Glial fibrillary acid protein (GFAP), Heart-type fatty acid binding protein (H-FABP), Interleukin 10 (IL-10), Neurofilament light protein (NF-L), Calcium-binding protein B (S100B) and Tauprotein T (t-tau) on admission ii) demographic data such as age and sex iii) type of injury (TBI with extracranial injuries/isolated) iv) lowest GCS when not intubated 13–15 vi) acute head CT findings and vii) data sampling delay available were included. Linear regression analysis was used to assess whether age, sex, or extracranial injuries affect blood biomarkers’ values.
Results: 129 patients were enrolled. There were 87 males (67%) and 42 females (33%), with a mean age of 47. In 74 patients (57%) the TBI was isolated, and 55 patients (43%) had TBI with other concomitant extracranial injuries. The levels of H-FABP, AB40, and NF-L were affected by age. The levels of GFAP were affected by sex. H-FABP and AB42 were affected by the presence of extracranial injuries.
Conclusions: We observed that levels of biomarkers are affected by age, sex or extracranial injuries. H-FABP and AB40 were both affected by age and the presence of extracranial injuries in patients with mTBI. These results indicate that before the investigated TBI biomarkers can be used in mTBI diagnostics, reference values for biomarkers should be defined for different patient groups.
635 Rehabilitation of hope. an anthropological study on the work of hope and involvement in the rehabilitation of adults with acquired brain injury with cognitive and communicative difficulties
Camilla Hojgaard Nejsta,b
aAalborg University, Aalborg, Denmark, bNeurorehabilitation Copenhagen, City of Copenhagen, Denmark
ABSTRACT
Background: According to research in neurorehabilitation, involvement in one’s own rehabilitation process and goal setting, especially in relation to psychosocial functions, has shown to be a prerequisite for optimal benefit and outcome of the rehabilitation (Levack, Weatherall, & Hay-Smith, 2015; National Board of Health, 2011). This requires that the perspective of the individual with an acquired brain injury (ABI) and possible caregivers form the starting point for the entire rehabilitation so that their wishes and hopes are in the center of goal setting and rehabilitation in general. According to Bright et al., listening actively and encouraging individuals to know that they are the expert in their own lives can help them identify their hopes and dreams (Bright, 2012). But how do we work with hope and involvement in a rehabilitation practice where the population is often characterized by having difficulties in relation to memory, reflection and spoken language? What is important for individuals with ABIs to feel involved in their own rehabilitation? And how do we translate this knowledge into goal setting and the general rehabilitation process in the future. The study includes adults with cognitive and communicative disabilities, since subjective experiences from persons with neurological impairments often are not seen as reliable or as important sources of information (e.g., Gracey et al., 2008).
Aim: The purpose of this PhD project is to contribute with knowledge about how to work with involvement and hope in the rehabilitation of people with ABIs who have cognitive and communicative difficulties and to gain insight into their experiences of being in a rehabilitation/recovery process.
Methods: This PhD project draws on anthropological methods such as observations and interviews. The project is situated at a large inpatient rehabilitation center, Neurorehabilitation Copenhagen, for adults with ABIs, who for a limited period receive intense rehabilitation in a municipal setting. Observations will be conducted of rehabilitation sessions, meetings, conferences, and everyday interactions between adults with ABIs and the health professionals working at the facility. Furthermore, interviews with adults with ABIs will be performed supported by tools such as Talking Mats and Supported Conversation for Adults with Aphasia (SCA). In addition, focus group interviews with professionals will be conducted.
Discussion: Studying the rehabilitation practice of adults with ABIs allows us to take a closer look into what is necessary if we want to make person-centered rehabilitation for people with cognitive and communicative difficulties. A rehabilitation that supports the population’s own perspectives and experiences in relation to involvement, with room for cognitive diversity.
Keywords: Rehabilitation, Acquired brain injury, Cognitive and communicative difficulties, Involvement, Hope.
699 Person-centered specialist community-based neurorehabilitation; the acquired brain injury Ireland suite of services
Karen Foleya
ABSTRACT
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland
Introduction: In Ireland, it is estimated that 120,000 people live with an ABI. ABI Ireland (ABII) is the leading provider of specialist community-based CARF-accredited neurorehabilitation services in Ireland. Since establishment in 2000, ABII championed development of person-centered, clinically governed services to meet the needs of brain injury survivors. Person-centredness permeates the organization with a deliberate organizational approach. Clinical governance ensures that design, provision and oversight of rehabilitation programmes is evidence-based.
Overview of Service Provision: In ABII, clinical governance under-pins all processes from referrals to assessment, service provision to discharge. We provide an inter-disciplinary approach to rehabilitation with input from Clinical Neuropsychology, Occupational Therapy, Social Work and Case Management. Routine clinical support is provided to frontline teams, which enables staff to respond in a consistent and effective manner to complex issues. The individual rehabilitation plan (IRP) is the foundation for rehabilitation provision. This plan ensures a holistic person-centered approach, which addresses all aspects of the person’s life and goals. ABII provides a Case Management Service to assist with organization, co-ordination and establishment of formal and informal networks of support to optimize functioning and well-being. ABII provides rehabilitation in Assistive Living Services where people are supported on the long-term or transitional programmes depending on needs and goals. The long-term programme supports people to achieve a fulfilled life in one of our assisted living services. The second programme has a primary focus on transitioning; it supports people whose goals are to move from our service to a less supported living arrangement in the community. The Home and Community Service is delivered to people living in their own homes and communities. This may include supporting people to engage in everyday activities, return to work or education. There is also access to bespoke supports through the organization’s Vocational Assessment and Rehabilitation Service and Assistive Technology Service to work on these specialist areas. The Day Resource Service is a place to meet, be accepted and work together toward a common goal of community re-integration. The service provides a person-centered approach, combining a range of cognitive, social, educational, creative and rehabilitation activities in a supportive environment. The organization also provides a network of Carer and Family Supports with information, training, advocacy and practical help. All services are underpinned by a deliberate organizational person-centered approach, from the mission and vision to the policies and procedures, recruitment and training to the IRP for each person served.
Conclusion: ABII’s vision is a society where brain injury is understood and all those impacted receive world-class, personalized rehabilitation and support, as and when they need it. Over the past 22 years, ABII has established and grown a suite of community-based neuro-rehabilitation services to address the needs of brain injury survivors across Ireland.
700 The importance of health economics research for effective decision-making, service-allocation and advocacy for neurorehabilitation organizations and people living with ABI
Grainne McGettricka
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland
ABSTRACT
Objectives: Health economic analyses related to acquired brain injury (ABI) and neurorehabilitation are key for effective policy and resource allocation decisions. Despite rising demand for neurorehabilitation services, a recent review (Mitchell et al, 2022) showed research examining cost-effectiveness of services is limited, and that funding for this type of research is severely lacking. As Ireland’s leading community neurorehabilitation provider for ABI survivors, and a nonprofit organization, it is crucial for Acquired Brain Injury Ireland (ABII) that the interventions we employ have good quality evidence behind them and can be shown to be cost effective. It is also necessary to have this type of data to provide to our funders and for advocacy.
Results: In 2010, an evaluation of the cost-effectiveness of ABII’s case management service was carried out in the North East area (Whelan, 2010). Due to the case management service’s success facilitating transitions from nursing homes and hospitals to settings with reduced supports, along with reducing admissions to both, it was estimated that €1.1 million was saved on average in each county of the North East area. A cost analysis examining different pathways followed by eight ABI survivors in 2015 (Foley, 2015) demonstrated the positive effects timely neurorehabilitation has on costs, compared to delayed discharge and delayed access to services. As the individuals in these case studies transitioned, where possible, to reduced support settings, the cost of care also decreased. Currently an internal research project by ABII aims to assess the effectiveness of providing acute periods of neurorehabilitation within an assisted living setting (higher cost service) followed by community neurorehabilitation (lower cost service), using the Mayo-Portland Adaptability Inventory-4 as an outcome measure. The cost of service within the two settings will be examined alongside outcomes to determine whether there is value in increased investment in transitional models of care within ABII. Increased provision of transitional models has the potential to allow the organization serve greater numbers of ABI survivors within shortened periods of time, on the assumption it is shown to be effective.
Conclusions: While some health economics research has been carried internationally, little can be said for an evidence base in Ireland. The international body of work that does exist has limitations, especially in regard to its strong focus on inpatient or acute settings. Since ABIs are one of the leading causes of lifelong disability, a greater focus ought to be placed on more long term and community-based neurorehabilitation interventions and the cost associated with the supports required during the lifetime post ABI. Further research is required to investigate the correlation between reduction of disability with ongoing neurorehabilitation and how that relates to long term cost of care, reduction in caregiver burden and increased social and vocational engagement.
701 The effectiveness of rehabilitation in the community and assisted living services of ABI Ireland using the MPAI-4 as an outcome measure
Caroline Donnellana
aAcquired Brain Injury Ireland, Dun Laoghaire, Ireland
ABSTRACT
Background: Since 2000, Acquired Brain Injury Ireland (ABI Ireland) has provided home and community rehabilitation services, which have expanded to include many areas in Ireland. While anecdotally services appeared effective for people who accessed them, it became necessary to incorporate more rigorous evidence-based outcome measures. Factors influencing this included the requirement to have hard evidence for our funder, the Health Service Executive, and evidence of rehabilitation effectiveness for accreditation purposes with the Commission for Accrediting Rehabilitation Facilities (CARF). The need to demonstrate effectiveness of neurorehabilitation is becoming increasingly required and is a hallmark of evidence-based practice.
Introducing the Mayo-Portland Adaptability Inventory (MPAI)-4:
The MPAI-4 yields a total score reflecting overall neuro-disability, and 3 subscales: the Ability, Adjustment, and Participation Indices. The Ability Index is composed of 13 items, the Adjustment Index includes 12 items and the Participation Index is made up of 8 items. Prior studies have demonstrated satisfactory internal consistency and construct validity, as well as concurrent and predictive validity, for the full measure and its indices. Since 2018, ABI Ireland have collected MPAI-4 scores at initial assessment and thereafter quarterly at clinical team meetings.
Objective: To examine the effectiveness of rehabilitation in ABI Ireland’s community and assisted living services using the MPAI-4 outcome measurement.
Methods: In this investigation, a comprehensive audit was completed using ABI Ireland’s existing outcome measurement database, which included records for 450 service users. Records for all service users for whom a baseline outcome measurement score was available and a minimum four timepoints were recorded were isolated for analysis. In line with the MPAI-4 handbook, raw scores were converted to T-scores and inputted to SPSS for analysis.
Results: When aggregated together, there was a decrease in mean MPAI-4 scores in our community (n = 100) and assisted living services (n = 18). It was identified that there were variances in the degree to which scores decreased or increased following service commencement.
Preliminary investigation (n = 118) indicated that people with greater decreases in scores have shorter average times between injury and service commencement.
Discussion: Further investigation is required to identify the factors influencing the degree of change reflected on the MPAI-4.
In the cases where no change or an increase was detected, further examination will be required to determine if there are other factors influencing the scores and to investigate if the MPAI-4 is an appropriate outcome measure for these cohorts.
827 Brain injury professional special issue: overview of brain injury and violence: moving past closed doors
Christina Dillahunt-Aspillagaa
aUniversity of South Florida, Department of Child & Family Studies, Rehabilitation & Mental Health Counseling, Tampa, USA
ABSTRACT
This issue of Brain Injury Professional that focuses on brain injury resulting from violence, with a focus on intimate partner violence (IPV).
Drs. Dillahunt-Aspillaga and Iverson are expert clinicians and researchers in brain injury and steeped in knowledge about brain injury that occurs in the context of IPV. Dr. Dillahunt-Aspillaga is a full Professor, rehabilitation scientist, rehabilitation counselor, life care planner and vocational expert with expertise in disabilities including brain injury, spinal cord injury, and employment. Dr. Iverson is a clinical psychologist whose work focuses on the intersections between mental health and IPV. In this issue, these guest editors assembled a series of articles that provide readers with a up to date overview of the extant literature examining brain injury in the context of IPV.
The feature article, entitled “Intimate Partner Violence and brain Injury: A Selective Overview,” was written by Dr. Eva Valera. In this article, Valera provides an overview of outcomes associated with IPV-related BI and highlight the various mechanisms of injury, including not only traumatic brain injury, but repetitive traumatic brain injury, as well as hypoxic-ischemic injury associated with strangulation. Valera also points out that IPV is a global public health concern that is often not identified or reported.
Other articles expand on specific issues and provide practical advice for providers. Iverson, Werner, Adams, and Galovski describe the comorbid mental health concerns that are commonly associated with brain injury in the context of IPV, including depression, PTSD, and substance use. The article by Fortier, Kim and Kenna provides a two-pronged approach to screening and assessment to identify and evaluate those with possible or suspected IPV-related brain injury more accurately. Fontain, Fox, and Reid discuss the impact of brain injury associated with violence in the context of environmental stressors and within under-represented and marginalized groups. Nine practice related services and legal interventions, that are unique to survivors of IPV, are outlined by Dillahunt-Aspillaga, Rumrill, Hendricks, Eagan-Johnson, Smith, and Rumrill. Additionally, two resources available to support survivors of IPV-related brain injury are described in the article by Nemeth, Haag, and Ramirez. The issue also includes an expert interview with Katherine Price Snedaker, the executive director and founder of Pink Concussions. Lastly, Dr. Stephen Trapp, provides a brief overview about an educational website developed to provide general information about the topic of IPV and brain injury for those experiencing or at risk.
858 Organizational change review of the GAA’s approach to concussion management in elite sport: a case study
John Windlea, Michael Collinsa, Anthony Kontosb, Hannah Bitzera, Eleni Theodirakic, Aaron Grantc
aUniversity of Pittsburgh Medical Center, Pittsburgh, USA, bUniversity of Pittsburgh, Dept. of Orthopedic Surgery, Pittsburgh, USA, cUPMC, University College Dublin, Technical University Shannon, Dublin, Ireland
ABSTRACT
As a result of growing media pressure and advice from health professionals, there is increasing pressure on sports organizations to change their management of concussions. There is growing support that Change is necessary to manage concussions in sports. Concussion has long been considered a known risk and part of sporting activity; however, there is now sound science to implicate concussion with long-term health problems (3). Sports organizations are actively working to change concussion management by improving concussion prevention, recognition, and treatment. However, organizational Change in sports still needs to be explored, with most change management frameworks developed from studies in business organizations (2).
Overview: This case study seeks to identify where improvements could be made by implementing new concussion management protocols within GAA Intercounty teams. Concussion Management is a high priority for the GAA as it affects a player’s health, could have future litigation implications, and influences the future of the sport. Therefore, a survey was sent to stakeholders directly involved in creating, managing, and implementing the changed approach to managing concussion within the GAA to understand better why Change was required and how the new policy was communicated and operationalized by Intercounty teams.
Results: A total of 16 Intercounty representatives responded to the survey. The findings suggest that an adaptable model based on (1) Lewin’s 3-stage model (unfreezing, changing, and refreshing) would work best for the GAA as opposed to a strict coercive change model due to the volunteer nature of the sport. The GAA successfully executed Stage 1, Unfreezing, with research and implementing new initiatives for concussion management, with 64% of those surveyed believing that Change is supported by leadership. Stage 2, Change, needs further focus on communication, empowering and involving people directly in the process, leading to improved chances of success. The survey highlighted that 63% of respondents stated that the new concussion management protocols were never communicated to them. Stage 3, Refreeze, will require further support to anchor changes in culture and the need to develop ways to sustain Change by providing support and training to guarantee the long-term success of the guidelines. This study showed that 19% of those surveyed said management turnover significantly impacts the change program.
Findings: The survey results demonstrate that the GAA has made progress in implementing Change. Extra resources and renewed focus could lead to successful organizational Change. The GAA could guide other sports organizations on how to implement organizational Change in concussion management.
References
1. Burnes, B., 2020. The origins of Lewin’s three-step model of Change. The Journal of Applied Behavioral Science, 56(1),pp.32–59.
2. Cruickshank, A. and Collins, D. (2012) ‘Change Management: The Case of the Elite Sport Performance Team,’ Journal of Change Management, 12(2), pp. 209–229.
3. Murray, I.R., Murray, A.D. and Robson, J., 2015. Sports concussion: time for a culture change. Clinical journal of sport medicine, 25(2),pp.75–77.
881 In the making and telling of a story; a neuropsychological approach to brain injury rehabilitation
Catherine Hol
This proposal is for a two part symposium or “special event.” The first part is showing a 23 min long documentary made by people with acquired brain injury about their lived experience as a part of their community neurorehabilitation programme at Headway Ireland.
The second part involves presenting a qualitative research project exploring participants experiences of therapeutic film making.
ABSTRACT
Purpose: A main goal of brain injury rehabilitation is to support individuals in their holistic journey to recovery post-injury. The holistic model is considered to be the leading approach in the continuity of care for persons with a brain injury as it emphasizes an understanding of the patient’s lived experience from a biopsychosocial perspective. This study considers using documentary-making as aholistic and novel paradigm to support the rehabilitation of people with a brain injury.
As research into the therapeutic benefits of film making on patients with a brain injury is pretty much undocumented, the aim of this study is to evaluate the potential of filmmaking as a transformative and therapeutic tool, as both the process and the product can be used as a medium, to engage in a process of self-discovery, awareness and expression.
Materials and Methods: A qualitative approach using semi-structured interviews was employed with ten project participants; including 7 service users with a diagnosis of non-progressive acquired brain injury, the artistic film director and two staff members; all of whom were invited to share their views and experiences of the project. The data was analyzed using an inductive bottom up approach to thematic analysis, common threads and patterns were identified and weaved to form a shared narrative of their experiences of the film-making process.
Results: Several themes emerged from analysis of the data that reflect the participants subjective experience of therapeutic filmmaking. Themes are organized based on their cohesiveness into two broad categories, and include the following superordinate themes: mastery, therapeutic alliance, social affiliation, film as catharsis and film as motivation.
Conclusions: The results yielded promising findings in relation to the therapeutic benefits of filmmaking as a medium for transformation and growth.
AUTHOR INDEXFootnote*
A
Abad-Lavara, Carlos, 92, 93, 94
Abbasi, Katherine, 252
Abdalmalak, Androu, 188
Abdeena, Nishard, 163
Abdulle, Amaal Eman, 137
Acher, Rose, 58
Acosta, Oliver, 4
Ada, Louise, 23
Adamson, Maheen, 172, 191, 195, 255
Adedotun, Kafayat, 47
Adelic, Nada, 76
Adelson, David, 223
Adhikari, Shambhu Prasad, 7, 186
Agnew, Rachel, 79
Agtarap, Stephanie, 33, 252
Ahmadi, Reihaneh, 166
Aida, Tamami, 5
Ainscough, Katie, 142
Akhlaghi, Hamed, 34
Alarie, Christophe, 28, 167
Albrecht, Ted, 101
Al-Hakeem, Hiba, 114, 212, 223, 231, 236, 249
Allain, Philippe, 80
Allanson, Judith, 214
Allen, Dean, 248
Allen, Niamh, 45
Alnagger, Naji, 87
Aloisi, Marta, 84
Alosco, Michael L., 257
Alvarez, Gemayaret, 19, 20
Alvarez-Gonzalez, Gemarayet, 4, 55
Amadiegwu, Akudo, 187
Ameis, Stephanie, 245
Amgalan, Anar, 255
Amor, Antonio Manuel, 170
Amorós, Desiré, 67
Analytis, Penelope, 43, 61, 62
Anandalingam, Suvendra, 77
Andelic, Nada, 66, 99, 138, 161, 196
Anderson, Gerard, 96
Anderson, Scott, 8
Anderson, Vicki, 166
Andersson, Stein, 84
Andreae, Mollie, 55
Andreu, Mauro Federico, 191
Andris, Cecile, 234
Angelakis, Efthymios, 213
Annen, Jitka, 64, 141
Aousji, Oumayma, 152
Appelros, Peter, 92, 135
Arango-Lasprilla, Juan Carlos, 148
Arany, Praveen, 160
Arbogast, Kristy, 8
Arciniega, Hector, 257
Arciniegas, David, 56
Ariës, Marcel, 148
Armitage, Bethan, 76
Armstead, Amber, 197
Arnaud, Saj, 206
Arnold, Dannae, 205
Aronson, Alex, 117
Arowolo, Ibiyemi, 47, 48
Arvidsson-Lindvall, Mialinn, 92, 94
Ashford, Stephen, 123
Ashton, Stephanie, 186
Ashworth, Fiona, 150
Aslam, Hira, 151
Atiah, Amr Saeed, 5
Aubinet, Charlène, 81, 82
Auchettl, Aylish, 78
Aussems, Céline, 120
Awais, Muhammad, 193
Aza, Alba, 184
Azouvi, Philippe, 71, 80, 81, 110, 156
Azurmendi, Leire, 80
B
Baath, Sukhman, 50
Babikian, Talin, 172
Babul, Shelina, 120, 186, 198, 244
Bacon, Blair, 54
Bagiella, Emilia, 215
Bagnato, Sergio, 213
Bahr, Roald, 256
Bahraini, Nazanin, 95
Bahri, Mohamed Ali, 64
Bailey, Brooke, 253
Bald, Caroline, 187
Balzeri, Ambra, 151
Barber, Jason, 109, 130
Barder, Helene Eidsmo, 84
Bardikoff, Tess, 212, 223
Barker, Sarah, 56
Barr, Alasdair, 239
Barra, Alice, 215
Barrass, Jennifer, 76
Barrett, Carrie, 30
Barrett, Emily, 57
Barry, Sarah, 151
Baschensis, Samantha, 52
Basit, Janita, 208
Bateman, Andrew, 227
Bates, Damien, 44
Bates, Erica, 230
Batey, Heather, 181
Bath, Jennifer, 124
Baumer, Thomas, 106
Bavishi, Sheital, 245
Bayen, Eléonore, 46, 80, 81
Bayen, Eleonore Pr, 199
Bayley, Mark, 56, 57, 93, 101, 196, 208, 211, 222
Bayley, Mark Theodore, 161
Beal, Deryk, 153, 227
Beard, Jack, 78
Beaton, Denise, 186
Beauchamp, Miriam, 74, 157, 176
Beaudoin, Cindy, 157
Beaudoin, Maude, 40
Beaulieu, Cynthia, 158
Beaulieu-Bonneau, Simon, 166, 168
Bechelet, Stephanie, 176
Bechke, Emily, 53
Becker, Frank, 21, 135
Bédard, Evelyne, 167
Behn, Nicholas, 10
Belanger, Heather, 15
Belding, Jennifer, 9, 22, 33
Beliy, Nikita, 64
Bell, Kathleen, 25, 109, 130, 210
Belton, Kathy L., 194
Bennett, Emily, 218
Bennett, Linda, 119
Bennett, Monica, 25, 26, 153
Bennett, Phoebe, 57
Bennett, William, 256
Benvegnu, Flora, 46
Beretta, Elena, 171
Bergin, Michael, 216
Bergin, Niamh, 219
Bergquist, Thomas, 21, 252
Beribisky, Nataly, 42
Bernard, Claire, 64, 234
Berwick, Steffen, 123
Best, Krista, 166
Bett, Robyn, 133
Betteridge, Shai, 76, 186
Beukema, Steve, 175
Bhaumik, Dulal, 117
Bhaumik, Runa, 117
Biddiss, Elaine, 231, 249
Bier, Nathalie, 166, 169, 173, 190
Biering-Sørensen, Fin, 148
Bigler, Erin, 172
Bisson, Abigail, 38
Bissonnette, Stephanie, 240
Bitzer, Hannah, 208, 262
Bjork, James, 16
Bjørnstad, Charlotte, 169
Black, Amanda M., 181, 194, 244
Blackwell, Laura, 103
Blankenship, Chynah, 237
Blázquez, Carmen, 67
Blennow, Kaj, 38, 80, 258
Blunt, Emily, 233
Böckers, Tobias M., 188
Bodien, Yelena, 214, 215, 216, 233
Bogner, Jennifer, 98, 158
Bol, Yvonne, 146
Bombardier, Charles, 21, 109, 129, 130
Bompard, Sarah, 147
Bonfert, Michaela V., 256
Bonhomme, Arthur, 87, 214
Bonhomme, Vincent, 87
Bonin, Estelle A.C., 60, 234
Bonke, Elena M., 256
Bonkowski, James, 9
Bonsangue, Valentina, 151
Borgen, Ida M. H., 66, 72, 158, 184
Borrego, Adrián, 64
Bosyj, Catherine, 50
Boto, Tamara, 117
Bottari, Carolina, 29, 48, 85, 88, 89, 90, 166, 169, 173, 190
Bottiglieri, Teodoro, 26
Bouix, Sylvain, 256, 257
Bouldin, Erin D., 220
Boulé-Riley, Stéphanie, 169
Bourke, Niall, 150, 183
Bouton, Nathaniel A., 201, 202
Boyle, Elizabeth, 198
Boyle, Noreen, 141
Bradford, Layla, 183
Brady, Nuala, 45
Bragge, Peter, 56
Braithwaite, Rock, 95
Brandt, Anne Elisabeth, 84
Brazill, Lindsay, 212
Breitenstein, Jackie, 171
Brenner, Lisa A., 95
Brett, Benjamin, 75
Breuer, Logan, 229
Brian, Jessica, 212
Briand, Marie-Michèle, 141
Brickell, Tracey A., 51, 52
Bridgman, Cara, 73
Brisson, Daniel, 54
Brodeur, Catherine, 167
Broglio, Steve, 8
Brosda, Ashley, 88, 89
Broussard, John, 56
Brouwer, Rineke, 155
Brown, Allen, 114
Brown, Allison, 99
Brown, Danielle, 223
Brown, Naomi, 115, 177, 182
Brown, Olivier, 163
Brown-Schmidt, Sarah, 70, 178
Bruguière, Pascale, 199
Brunet, Eric, 156
Brunner, Iris, 67
Brunner, Robert, 21, 253
Bryant, Adam, 23
Bubel, Emily, 204
Buckland, Gemma, 165
Buckley, Caitlin M. Ogram, 204
Buckley, Dani, 243
Buckley, Thomas, 8
Buffières, William, 40, 90
Bulas, Ashlyn, 233
Burke, Matthew, 230
Burke, Sarah, 255
Burke, Teresa, 176, 220
Burmester, Alex, 34
Burnett, Jake, 34
Burns, Annmarie, 176
Burns, Katie, 115, 177
Burnstein, Brett, 157
Bus, Boudewijn, 14, 18, 20, 106
Bushnik, Tamara, 33, 98
Butler, Phil, 170
Butler, Philomena, 43, 70
Butterfield, Kaitlyn, 50
Butz, Megan, 52
Buunk, A. M., 224
Buunk, Anne M., 65, 85
Byom, Lindsey, 206
C
Caccese, Jaclyn, 8, 99
Caeyenberghs, Karen, 34
Caine, Yehezkel G., 91
Caird, Robin, 208
Calhoun, Katie, 54
Calhoun, Stephanie, 25, 26, 27, 221
Callender, Librada, 25, 26, 221, 254
Câmara-Costa, Hugo, 80, 81
Cameron, Ian, 134
Campagnini, Silvia, 65
Campbell, Anne, 182
Campbell, Christina, 254
Campbell, Thomas, 113
Cantellops, Natalia Miranda, 125
Canty, Alison, 256
Caporro, Sara, 147
Cardone, Paolo, 87, 214
Carli, Silvia, 151
Carminati, Jao, 62
Carmona, Jerina, 214–215
Carolan, Caoimhe, 150
Carolan, Terrence, 6
Caron, Jeffrey G., 181, 183, 194
Carr, Lawrence, 107, 110, 113, 121
Carrière, Manon, 81
Carroll, Cliodhna, 76, 186
Carroll, Paul, 146, 147
Carton, Simone, 45
Casachahua, John, 54, 55
Casey, Carla, 131
Casey, Sarah, 147, 170
Cassidy, Shane, 192
Castellanos, Paula, 73
Castelli, Enrico, 147
Castillo, José Luis, 170, 184
Castillo, Marie-Carmen, 140
Castro, Luis, 207
Cente, Martin, 256
Cerezo, Silvia, 67
Chaban, Viktoriia, 258
Chagpar, Sakina, 78
Chandra, Tharshini, 101, 208, 211
Chang, Elbert, 218, 219
Chang, Kevin, 215
Chassman, Stephanie, 54
Chatelle, Camille, 81, 215
Chaubey, Kalyani, 56
Chaudhari, Nikhil, 255
Chavet, Valérie, 120
Chawla, Rohan, 219
Checklin, Martin, 131
Chen, Jen-Kai, 185
Chennu, Srivas, 215
Chestnut, Amanda, 239
Chevignard, Mathilde, 80, 81, 144
Chevreau, Gaëtan, 140
Chi, Bradley, 12
Chiaretti, Antonio, 147
Chiariello, Rachel, 112
Chin, Bridget S., 9
Chizuk, Haley, 38, 160
Cho, Yoo-bok, 63
Choi, Heelak, 63
Choi, Hye Yeon, 63
Choi, Nakwon, 63
Chowdhury, Nahian, 255
Chrisman, Sara, 8
Christoforou, Andrea, 216
Chu, Bernice, 124
Chuah, Sarah, 130, 134
Chung, Joyce, 98
Chung, Samuel, 33
Ciccia, Angela, 157, 178
Cifu, David, 15
Cintron-Perez, Coral, 56
Claassen, Jan, 215
Clanchy, Kelly, 78
Clare, Griffin, 149
Clark, Ross, 23
Clarke, Gerard, 258
Clough, Sharice, 48, 122, 178, 221
Clugston, Jay, 8
Coelho, Carl, 10
Coetzee, John, 195
Coffeng, Sophie, 137
Coffey, Deirdre, 219
Cogne, Mélanie, 71, 110
Cohen, Neal J., 187, 194, 201, 202
Colantonio, Angela, 167
Cole, James, 172
Coleman, Michael, 257
Colgan, Léana, 180
Collier, Bryan, 124
Collins, Michael, 95, 101, 208, 262
Collins, Simonne, 166
Colomer, Carolina, 64, 66, 67
Comper, Paul, 101, 208, 211
Comyns, Thomas M., 136
Conklin, Jessica, 171
Conklin, Jessica Pan, 35
Conlon, Ellen, 142, 145, 231
Conneely, Mark, 117
Connolly, Anne, 145
Connolly, Laura, 37
Conroy, Patricia, 147
Conroy, Rowena, 79
Conte, Mary, 215
Convery, Claire, 147
Conway, Nora, 3
Cook, Lawrence, 16
Cordsen, Pia, 61
Corneyllie, Alexandra, 90
Corneyllie, Eng Alexandra, 40
Cornish, Rosie, 27
Correll, Rhonda, 32
Corridan, Isabelle, 255
Corrigan, Catherine, 176, 220
Corrigan, John, 8
Costello, Gemma, 218
Couture, Mélanie, 85, 169, 190
Covington, Natalie, 48, 127, 193, 194, 200
Cowan, Katherine, 32
Cowle, Stephanie, 194
Cox, Marie, 29
Cox-Whitney, Molly, 253
Craig, William, 74
Cramer, Steven C., 44
Cristaudo, Kendal E., 52
Cron, Greg O., 163, 164
Cross, Nuala, 149
Crowe, Louise, 166
Cruse, Damian, 175
Cruse, Nicole, 10
Cummings, Jeffrey L., 257
Cunningham, Joice, 141
Curro, Valentina, 82
Cury, Claire, 24
Cutlan, Rachel, 112
Czykier, Anna, 99
D
Da Silva Ramos, Sara, 176
Daher, Maysaa, 134, 250
Dailler, Frédéric, 40
Dams-O’Connor, Kristen, 153, 172, 233
Danells, Cynthia, 208
Dang, Norman, 208
D’Arcy, Ryan C. N., 226, 229
Dardenne, Nadia, 60
Dart, Libby, 157, 178
David, Tate, 14
Davidson, Lance, 107, 110, 113, 121
De Bellis, Francesco, 209
De Guise, Elaine, 28, 175
De Jesús-Cortés, Hector, 56
de Koning, Myrthe, 137
de la Fontaine, Sally, 226
de Leeuw, Sanne, 205
De Loor, Pierre, 173
De Luca, Alberto, 256
De Mora, Holly, 174
de Riesthal, Michael, 127
de Souza, Nicola, 233
Debert, Chantel, 254
Debicki, Derek, 188, 202
deBoer, Heather, 241
Decq, Philippe, 110
Degeilh, Fanny, 24
Dehaene, Stanislas, 215
Dehollain, Charlotte, 46
Dei Vecchi, Lara, 191
Delargy, Mark, 45, 124, 145
Dell, Lynn, 198
Dellatolas, Georges, 80, 81
Demarchi, Célia, 150
Dempsey, Maria, 3
Dennis, Emily, 172, 191, 195
Denniss, Rebecca, 69
Denvir, Karl, 141
Dery, Julien, 175
Desai, Nilesh K., 2
Desrocher, Mary, 42
Devereux, Megan, 150
Dhadwal, Neha, 218, 219
Diachek, Evgeniia, 70
Diaz, Lorenzo, 20
Dickey, James P., 224
Dijkers, Igor, 96
Dikenstein, David, 60
Dillahunt-Aspillaga, Christina, 261
Ding, Kan, 210
Dismore, Harriet, 102
Doan, Quynh, 74
Dobryakova, Ekaterina, 172
Dockree, Paul, 146
Dockree, Suvi, 146, 149
Dodick, David, 229
Doig, Emmah, 131
Domensino, Fleur, 148
Dominguez, Juan, 34
Donald, Kirsten, 183
Donnellan, Caroline, 261
Donners, Babette, 148
Dornonville de la Cour, Frederik Lehman, 148
Dorrego, María Flavia, 191
Dougherty, Amber, 54, 55
Douglas, Jacinta, 56, 59
Douglas, Megan, 25, 26
Dowd, Haulie, 53
Downing, Marina, 46, 119, 234, 235
Drake, Emma, 29
Drake, Marnie, 43
Dreer, Laura, 8, 21, 113, 252, 253
Driver, Simon, 8, 25, 26, 27, 109, 130, 205, 221, 254
Duba, Milos, 11
Dubiel, Randi, 25, 26
Dubiel, Rosemary, 205, 221, 254
Dubois, Laurie, 166
DuBois, Samantha, 53
Duclos, Cyril, 206
Duclos, Noemie, 206
Duff, Melissa C., 19, 48, 50, 70, 121, 122, 127, 166, 178, 187, 193, 194, 201, 202, 221, 236, 238, 246
Duffy, Donna, 53
Duffy, Emer, 145
Duffy, Lorraine M., 86
Duffy, Orla, 79
Dugdale, Fred, 47
Duits, Annelien, 86
Dulas, Michael R., 187, 201, 202
Duncan, Lindsay, 167
Dunkley, Benjamin, 230
Dunlop, Laura, 79
Dunn, Jeff, 254
DuPlessis, Danielle, 50, 231, 249
Dupont, Dominique, 157
Dussault, Bénédicte, 166
Dwyer, Brigid, 240
Dwyer, Liam, 28
E
Eagan-Johnson, Brenda, 178, 198
Eagle, Shawn, 95
Eastes, Alicia, 201
Echlin, Holly, 185
Eckner, J. T., 8
Edelman, Lyndsey, 68
Edlow, Brian L., 213, 215, 233
Edwards, John, 118
Edwards, Malcolm, 48, 236
Egeland, Jens, 158, 184
Eggertsen, Peter P., 60, 61, 142
Ehlers, Shelley, 31
Ehman, Richard, 114
Eide, Line Sophie, 137
Einarsen, Cathrine, 258
Einarsen, Cathrine Elisabeth, 192
El Dyasty, Shaimaa, 5
Eliason, Paul, 198
Eliassen, Carl Fredrik, 63
Elliott, Timothy, 58
Emery, Carolyn A., 181, 183, 194, 198, 217, 241, 242
Enblad, Per, 159
Engel, Lisa, 47, 48, 88, 89, 90
Engelbert, R. H. H., 104
Engelbert, Raoul, 105, 136
Englert, Robyn, 9, 33
Erickson, Jennifer, 129
Eriksson, Olivia, 94
Erler, Kimberly, 33
Ermer, Elsa, 8
Escobar, Andres, 73
Esopenko, Carrie, 8, 99, 107, 110, 113, 121
Esterov, Dmitry, 109, 114, 130, 153
Estraneo, Anna, 84, 209, 213
Eugene, Dajuandra, 97
Evald, Lars, 180
Evans, Emily, 33
Evans, Melissa, 178
Ewesesan, Roheema, 47, 48
Ezan, Pauline, 87
Ezepue, Adora, 56
F
Falco, Christopher, 237
Fang, Zhuo, 163, 164
Fann, Jesse, 129
Farouk, May M., 5
Farrell, Garreth, 141
Fassbender, Catherine, 156
Fawaz, Shereen, 5
Fedele, Bianca, 58
Feeney, Tim, 46, 61
Fehlings, Darcy, 153
Fenton, Kaitlyn, 198
Fereydoonpour, Mehran, 13
Fernández, María, 170, 184
Ferre, Fabrice, 40, 90
Ferrea, Monica, 191
Ferri, Giulia, 84
Ferri, Joan, 64, 65, 67, 168
Ferschmann, Lia, 24
Ffrench, Cathal, 146
Fheodoroff, Klemens, 123
Fiadzomor, Peace, 249
Fickling, Shaun, 226, 229
Field, Thalia, 239
Filipcik, Peter, 256
Finn, Jacob, 98, 113
Finn, Susan, 193
Finnanger, Torun Gangaune, 84
Fino, Peter, 121
Finoia, Paola, 215
Fins, Joseph, 215
Fisher, Lauren, 113
Fisher, Renae, 16
FitzGerald, Alasdair, 162
Fitzgerald, Michelle, 225
Fleming, Jennifer, 131
Fogarty, Bríd, 150
Fogarty, Kieran, 30
Foley, Karen, 260
Follestad, Turid, 71, 72, 258
Fong, Alina, 118
Fordal, Linda, 192
Formisano, Rita, 84, 213
Forslund, Marit V., 66, 72, 76
Forster, Jeri, 95
Foster, Evan, 101, 208, 211
Foussard, Margaux, 71
Francillette, Leila, 81
Fraser, Elinor, 119, 234
Freer, Caroline, 239
French, Louis, 51, 52
Frencham, Kate, 37
Friedman, Simone, 15, 40
Frishberg, Benjamin M., 44
Frizzell, Tory, 229
Froehlich, Albrecht, 152
Frøyland, Kaia, 169
Fuller, David, 211
Fure, Silje Christine Reistad, 66, 76, 99, 161, 196
G
Gagnon, Isabelle J., 28, 157, 194
Gagnon-Roy, Mireille, 85, 190
Gainforth, Heather L., 77, 186
Gal, Roman, 11
Galarneau, Jean-Michel, 194, 198
Gallow, Sara, 145
Galvin, Jen, 3
Gangwani, Rachana, 213, 217
García-Hernández, Juan José, 92, 93, 94
García-Martín, Fuensanta, 93
Gargaro, Judith, 57, 196
Gargaro, Judy, 93, 222
Garnett, Anna, 249
Gartell, Rebecca, 108, 109
Gary, Kelli, 113
Gates, Thomas, 134
Gatineau, Maryame, 110
Gaynor, Jocelyn, 40
Genova, Helen, 172
Gerald, Brittany, 223
Gheta, Ioana, 167
Giacino, Joseph, 33, 215, 216
Gicas, Kristina, 239
Gignac, Monique A. M., 90
Gignac, Monique M. A., 89
Gill, Irwin, 111, 155, 193
Gill, Jessica, 52
Gill, Peter, 32
Gill, Renee, 78
Gilles, Marlène, 173
Gillespie, Jaime, 205
Gillow, Kelly C., 52
Gioia, Gerard, 248
Giordano, Katherine, 241
Girard, Hugo, 29
Giroux, Sylvain, 169, 173, 190
Gladstone, Jonathan, 211
Glista, Danielle, 251
Gober, Joslyn, 4
Gobert, Florent, 40
Gofton, Teneille E., 188, 202
Goldenstein, Samantha, 53
Goldfield, Gary, 163
Goldin, Yelena, 21
Goldstein, Benjamin, 230, 232
Gomes, Dean, 101
Gonzales-Lara, Laura, 175
Gonzalez, Maria Cecilia, 191
González-Alted, Carlos, 92, 93
Goodwin, Emily, 54
Gooijers, Jolien, 256
Goostrey, Kesley, 215
Gore, Russell, 68, 108, 171
Gorgens, Kim, 54
Gorisek, Veronika, 96
Gormally, Conor, 251
Gormally, Malayka, 251
Gorter, Jan Willem, 104, 105, 136
Gosselin, Nadia, 85, 190
Gosseries, Olivia, 60, 64, 81, 84, 87, 120, 141, 213, 215, 234
Gouin-Vallerand, Charles, 29
Gould, Kate, 46, 61, 62
Gouriou, Clementine, 199
Grabowski, Annie, 200
Grafman, Jordan, 172
Graham, Laura, 224
Granger, Aurélie, 110
Grant, Aaron, 262
Gravel, Jocelyn, 74, 157
Gray, Dee, 124
Green, Robin, 56
Green, Tabitha, 223
Griblot, Jade, 110
Grier, Ava, 239
Griffin, Claire, 225
Griffin, Janelle, 131
Griffiths, Daniel R., 241
Grima, Natalie, 37
Grippo, Antonello, 213
Groen, Rob J.M., 65, 85
Groysman, Leonid I., 44
Guderian, Tanner, 107, 110, 113, 121
Guernon, Ann, 117
Gullo, Hannah, 77, 131, 166
Gumarang, Jeanette, 218, 219
H
Haarbauer-Krupa, Juliet, 97, 116
Haberg, Asta, 172
Hade, Erinn, 158
Hadzic-Andelic, Nada, 143
Haeren, Roel, 148
Hagel, Brent E., 198, 217
Hagen, Erika, 178
Haider, M. Nadir, 38
Haider, Mohammad, 160
Haines, Kerrie, 119
Hakes, Catherine Wiseman, 101
Hale, James, 141
Hall, Marissa, 39
Hämäläinen, Heikki, 139
Hameed, Hajr, 208
Hammond, Flora M., 98, 153, 216, 252
Hampshire, Adam, 150
Hamzah, Norhamizan, 39
Hamzaid, Nur Azah, 39
Hanak, Tyler, 118
Handmaker, Hirsch, 247
Hanks, Robin, 24
Harcum, Stacey, 8
Harik, Lindsey, 237
Harnett, Amber, 56, 57, 161
Harrison, Courtney, 213, 217
Harrison, Elizabeth, 33
Harton, Brett, 117
Harvey, Ellen, 124
Hassett, Leanne, 23, 78
Hastings-Ison, Tandy, 123
Hauger, Solveig L., 66, 72
Haughey, Fiona, 45, 124
Hawley, Lenore, 7
Hayes, Kati, 106
Hays, Kaitlin, 52
Hays, Leanne, 142
Hayward, Chloe, 218
Healey, Katherine, 163, 164
Healy, Andrea, 156, 176, 220
Heegers, Amber, 224
Heine, Kate, 43
Heine, Lizette, 40, 90
Heinen, Florian, 256
Heinicke, Megan, 243
Heinonen, Gregory, 215
Hellemose, Amalie, 142
Hellemose, Line Amalie, 160
Hellstrom, Torgeir, 172
Hendricks, Sharief, 217
Hendryckx, Charlotte, 29, 85
Heran, Manraj, 239
Hernández, Alba Aza, 170
Herrin, Ileana, 237
Hertz-Pannier, Lucie, 156
heslot, Camille, 71
Heuvel, Florian Olde, 152, 188, 189
Heyn, Patricia, 9
Hickey, Robert, 95
Hickling, Andrea, 114, 122, 203, 212, 223, 236, 249
Hicks, Amelia, 46, 61, 62
Hietanen, Marja, 83
Hill, Bridget, 123
Hillary, Frank, 172, 195
Himanen, Leena, 111
Hirano, Kaori, 251
Hirschberg, Ron, 215
Hoare, Brian, 123
Hodge, April, 68
Hodges, Cooper, 16, 172
Hoepner, Jerry, 69, 128
Hoffman, Jeanne, 233
Hogarth, Lee, 27
Hol, Catherine, 3, 262
Holahan, Matthew, 203, 204, 205
Holden, Alexandria, 25, 26
Holden-Downes, Jill, 228
Holloway, Mark, 82, 83, 100, 248
Holnthaner, Rok, 96
Holth, Kristian, 61
Holthe, Ingvil Laberg, 158, 184, 190
Home, Sally, 250
Hoover, Rachel, 240
Hopwood, Malcolm, 46, 128
Horn, Janneke, 86
Hossain, Iftakher, 258
Hosseini-Moghaddam, Sam, 244
Hossin, Meherunnessa, 117
Hotzé, Fanny, 249
Hough, Lauren, 196
Hovenden, Elizabeth, 107, 110, 113, 121
Howarth, Robyn, 103
Howe, Emilie, 76
Howe, Emilie Isager, 99, 161, 196
Hrabi, Gladys, 89, 90
Hrdý, Ondřej, 11
Hsiao, Yu-Yu, 58
Hu, Yaxin, 121, 246
Huang, Ching-Lung, 238
Huard, Eliane, 207
Huard, Lydia, 89
Hubbard, Christa, 214
Huber-Lang, Markus, 189
Huhtasalo, Jenni, 36
Huisman, Thierry A. G. M., 2
Huling, Jared D., 179
Humbert, Ilia, 97
Hung, Ryan, 153
Hungerford, Lars, 52
Hunsake, Naomi, 14
Hunt, Anne, 48
Hur, Rachel, 198
Husain, Aisha, 238
Hustinx, Roland, 60, 64, 234
Huston III, John, 114
Hutchinson, Elizabeth B., 241
Hutchinson, Peter, 38, 80, 258
Hutchison, Michael, 228, 249
Hwang, Jill, 234, 235
Hwang, Juwon, 238
Hypher, Ruth, 84
Hyung, Jiwon, 56
Hyzak, Kathryn, 7
I
Igoe, Anna, 45
Imai, Hideaki, 44
Inness, Elizabeth, 101, 208
Iosa, Marco, 84
Ippolito, Christina, 228
Irimia, Andrei, 172, 255
Irwin, Meg, 32, 49
Isaksen, Jytte, 155
Izadi, Ensieh, 256
Izumi, Shin-Ichi, 5
J
Jackson, Hayley, 131
Jackson, Howard, 248
Jacobs, Chloe, 183
Jacobsson, Lars, 105
Jain, Divya, 99
Jak, Amy, 15
James, Glenda, 89
Jannace, Kalyn, 8
Janzen, Shannon, 56, 57, 161
Jarl, Gustav, 92, 94, 135
Javadpour, Mohsen, 219
Jeffay, Eliyas, 56
Jeffery, Rachel, 76
Jeffery, Sarah, 31
Jenkin, Taylor, 43, 79, 166
Jennings, Sabrina, 95
Jensen, Gary, 218, 219
Jha, Ruchira, 172
Jobin, Kaiden, 254
Johansen, M. A. Truls, 21
Johansen, Truls, 135
Johansson, Birgitta, 139, 140
Johnsen, Søren Paaske, 61
Johnson, Hailey L., 246
Johnson, Liam, 78
Johnson, Paula, 107, 110, 113, 121, 172
Johnson, Susan, 97
Johnston, Deborah, 134
Johnstone, Brick, 53, 171
Jones, Andrea, 239
Jones, Shawn, 123
Jordan, Julie- Ann, 79
Jorge, Ricardo, 56
Jorgensen, Marda, 211
Jorna, Lieke S., 65, 85, 224
Joseph, Annie-Lori, 243
Joseph, Justin, 9
Jourdan, Claire, 80, 81
Joyce, Oisin, 141
Juengst, Shannon, 25, 26, 33, 113
Jung, Eujene, 11, 31, 125
Jung, Leonard B., 256, 257
Jung, Noah B., 256
Jung, Yong-Gyun, 63
Junge, Moira, 37
Junghenn, Tara, 150
Junn, Cherry, 129, 247
Jurick, Sarah, 54, 55
K
Kakonge, Lisa, 121, 238, 244
Kalymon, Natalie, 40, 248
Kam, Alice, 211, 238
Kandah, Maya, 218
Kang, Xiaojian, 191, 195
Kankam, Keren, 249, 251
Karami, Ghodrat, 13
Kardish, Rachel, 163
Karic, Tanja, 199
Karmali, Shazya, 194, 244
Karmarker, Amol, 16
Karpa, Jane, 48
Katila, Ari, 80
Katz, Doug, 215
Katz, Douglas, 240
Kaufmann, David, 256
Kaufmann, Elisabeth, 256
Kaux, Jean-François, 120
Kawabori, Masahito, 44
Kazazian, Karnig, 188, 202
Kazis, Lewis, 33
Keegan, Dylan, 142
Keegan, Louise, 69
Kehoe, Anne, 149, 164
Kekes-Szabo, Sophia, 122
Keleher, Finian, 107, 110, 113, 121
Kelly, Aine, 141
Kelly, Elaine, 150
Kelly, Glenn, 237
Kelly, Louise, 8
Kelly, Simon, 227
Kelm, Laoise, 150
Kemp, Amy, 108, 109
Kendall, Michael, 43
Kennedy, Areti, 31, 132, 133
Kennedy, Eamonn, 220
Kennedy, Jan, 52
Kennedy, Mary, 56
Kennedy, Niamh, 89
Kennedy, Richard, 21, 253
Kenney, Kimbra, 16
Kenny, Ian C., 136
Kenny, Siobhan, 149, 225
Kent, Hope, 27, 68
Kerr, Brynna, 228
Kersalé, Marietta, 28
Kesari, Santosh, 44
Ketchum, Jessica M., 98, 113
Keys, Alison, 228
Khan, Ajmal, 249
Khan, Fatima, 238
Khan, Mohammad, 48
Khosdelazad, S., 65, 85, 224
Killi, Eli Marie, 190
Kim, Anthony S., 44
Kim, Byul, 63
Kim, Jiyoung, 63
Kim, Mina, 63
Kim, Minseo (Sunny), 244
Kim, Sonya, 9
King, Anna, 256
King, Jade, 76
King, Rachel, 39
King, Samuel E., 95
King, Sarah, 243
Kinney, Adam, 95
Kinsella, Fiona, 219
Kirby, Amanda, 27
Kirby, Eric D., 226
Kitchens, Riqiea, 197
Kleffelgård, Ingerid, 66, 72, 138, 143
Kletzel, Sandra, 117
Klinkhammer, Simona, 86
Klyce, Daniel W., 33, 98, 113, 252
Knapp, Brenda, 212
Knight, Sarah, 43, 79, 166
Koerte, Inga K., 256, 257
Koffijberg, Ralf, 65, 85
Kohnen, Roy, 1, 2
Kolaja, Claire, 22
Kolarova, Amy, 125
Koliatsos, Vassilis, 172
Kolisnyk, Matthew, 188, 202
Kolstad, Ash, 198
Kontos, Anthony, 95, 101, 208, 262
Kool, Isaac J., 77
Kooyman, Joyce, 148
Kordt, Eline Aase, 169
Korhonen, B. M. Otto, 38, 79
Kothari, Sunil, 12
Kralik, Stephen F., 2
Kramer, Kaye, 25
Krasny-Pacini, Agata, 144
Krese, Kelly, 117
Kreter, Nicholas, 121
Krishnan, Shilpa, 9
Kroshus, Emily, 228
Kua, Ailene, 56, 57, 161
Kumar, Raj, 33, 233
Kunzman, Kira, 251
Kurki, Timo, 139
Kuruvilla, Maneesh, 256
Kwabena, Sarpong, 2
L
Labib, Hossam, 5
Lafleur, Karine, 166
Lagerstedt, Linnea, 80
Lähdesmäki, Tuire, 111
Lam, Brendan, 122, 203, 212, 223
Lam, Emily, 231, 249
Lamberti, Gianfranco, 213
Lamontagne, Marie-Eve, 175, 210
Lang, Donna, 239
Lange, Rael T., 51, 52
Langer, Laura, 101, 196, 211, 222
Langford, Diane, 8
Lannsjö, Marianne, 159
Lapointe, Andrew, 254
Larkin, Elizabeth, 237
Larroque, Stephen, 234
Larson, Michael, 107, 110, 113, 121
Lasprilla, Juan Carlos Arango, 123
Laurent-Vannier, Anne, 81
Laureys, Steven, 60, 64, 81, 84, 87, 141, 215, 234
Lavezzi, Susanna, 151
Lawrence, David, 211
Lawrence, Phoebe, 215
Le Dorze, Guylaine, 169
Leahy, Sharon, 29
Leahy, Sinead, 111
Lebrault, Helene, 144
Lebrun, Constance, 198
Leckie, George, 27
Leclaire, Éliane, 29
Lecours, Sophie, 88, 89, 90
Leddy, John, 38, 160
LeDorez, Guylaine, 190
Ledoux, Andrée-Anne, 74, 163, 164
Ledoux, Didier, 60, 141
Lee, Jeong Ho, 125
Leemans, Alexander, 256
Lefevre, Clemence, 71
Lefevre-Dognin, Clémence, 110
Legace, Elizabeth, 32
Leguizamon, Florencia Giselle, 191
Leigh, Owen, 226
Leinders, Math, 143
Lejeune, Nicolas, 60, 87, 120, 213
Lemsky, Carolyn, 88, 89, 190
Lengenfelder, Jean, 252
Leonard, Julie C., 179
Leonova, Olga, 239
Lequerica, Anthony, 8
Levac, Danielle, 153
Levine, Deborah, 176
Lewén, Anders, 159
Lexell, Jan, 105, 159
Li, Chih-Ying, 197, 253
Li, Sheng, 12
Li, Shun, 152, 188
Li, Ying, 211
Li, Zhenghui, 152, 188
Liebel, Spencer, 107, 110, 113, 121
Lifshitz, Jonathan, 241
Lim, Hajin, 121, 166, 246
Lin, Alexander P., 256, 257
Lindeløv, Jonas K., 137
Lindley, Kate, 56
Lindsey, Hannah, 107, 110, 113, 121, 172
Lindvall, Mialinn Arvidsson, 135
Liou-Johnson, Victoria, 191, 195
Lippa, Sara A., 51, 52
Liston, Mairead, 136
Liu, Yulun, 210
Liuzzi, Piergiuseppe, 213
Livengood, Sherri, 117
Livny, Abigail, 172
Ljungqvist, Linda, 139
Llorens, Roberto, 64, 66, 67, 168
Lockley, Steven, 37
Loewen, Jaycie, 118
Løke, Daniel, 196
Lovell, Andrew, 212, 223, 236
Løvstad, Marianne, 21, 66, 72, 76, 99, 135, 138, 158, 161, 172, 190, 196
Lowran, Alison, 125
Lu, Juan, 76
Luauté, Jacques, 40
Lucas, Charlotte Dehollain, 199
Lund, Anne, 135
Lundgren, Kristine, 9
Lundine, Jennifer, 178, 179
Lunkova, Ekaterina, 173, 185
Luttenbacher, Ines, 195
M
Maanpää, Henna-Riikka, 79, 258
Mac Donald, Christine, 233
Macarthur, Colin, 32
Macca, Marina, 151
MacEwan, George, 239
MacGregor, Andrew, 54, 55
Macpherson, Alison, 194
Madorsky, Irina, 211
Madsen, Benedikte, 161, 196
Magat-Mabanta, Kimberly, 243
Magee, Wendy, 124
Magliacano, Alfonso, 84, 209, 213
Mah, Katie, 212
Maher, Alexander, 255
Maheshwari, Saumya, 28
Mahoney, Elaine, 21
Maisel, Éric, 173
Maitz, Michelle, 130
Majerus, Steve, 81
Mäki, Kaisa, 83
Mallinson, Trudy, 253
Mallory, Kylie, 212, 228, 236
Malmi, Katja, 258
Malone, Christopher, 215
Mann, Georgina, 126, 131
Mann, Kilby, 239
Manning, Danielle, 70
Mannini, Andrea, 65, 213
Manolov, Rumen, 144
Mantell, Andy, 7
Mantik, Christopher, 218, 219
Marcus, Esther-Lee, 91
Maritial, Charlotte, 84
Markiv, Anna, 248
Marshall, Rory A., 77
Marshall, Sara, 122, 203
Marshall, Shawn, 56, 161
Martens, Geraldine, 215, 216
Martial, Charlotte, 87
Martin, Jeffrey, 41
Martindale, Sarah, 16
Martini, Angelita, 126, 131, 133
Martini, Rose, 144
Martin-McKeever, Maria, 177
Martins, Bernardo, 207
Martinsen, Anne Catrine Trægde, 21, 135
Marwitz, Jennifer, 21, 252
Masel, Brent E., 58
Mason, Karen, 7, 186
Massett, Roy, 255
Master, Christine, 8
Matérne, Marie, 92, 94, 135
Mathers, Paula, 49
Matre, Martin, 21, 135
Mayberry, Lindsay, 19
Maza, Anny, 168
Mazo, Guillaume, 156
Mazuéb, Lucie, 82
Mazwi, Nicole, 215
Mazzone, Olivia, 79
McAllister, Peter, 44
McAllister, Thomas, 8
McBride, Daniel, 252
McCabe, Cameron, 54
McCabe, Sarah, 185
McCaffrey, Sinead, 149
McCann, Alison, 45, 46, 145
McCarthy, Elizabeth, 159
McCauley, Katherine, 68, 171
McCavert, Mary-Elaine, 49
McCrea, Michael, 8, 95
McCrudden, Eunan, 32, 115, 162, 177
McCulloch, Karen, 206, 213, 217
McCurdy, Ryan, 48, 193, 194, 200
McCusker, Chris, 32
McDevitt, Jane, 8
McDonald, Michelle, 88, 89, 90
McDonald, Scott, 16
McDonald, Skye, 21
McElligott, Jacinta, 149
McEvoy, Orla, 180
McFarland, Stephanie, 249
McFarlane, Jean, 174
McGettrick, Grainne, 12, 176, 220, 260
McGinley, Jennifer, 145
McGuire, Brian, 146, 149, 177
McGuire, Shannon, 224
McIntyre, Amanda, 56, 161
McKay, Adam, 37, 56, 128, 131, 161
McKee, William, 39
McKenzie, Dean, 58
McKerral, Michelle, 28
McLean, Heather, 189
Mclean, Jayse, 13
McLennan, Vanette, 31
McLoughlin, Rebekah, 150
McMillan, Tom, 151, 162, 174
McMoreland, Claire, 150
McNerney, Orla, 155
McPherson, Jacob, 38
McRae, Philippa, 134, 250
McShan, Evan, 25, 26, 27
McVean, Julia, 151
Mehmel, Bindal, 101
Melega, Greta, 221
Melkas, Susanna, 83
Mellick, Dave, 74
Mélotte, Evelyne, 120
Méndez, Ángela, 64
Menon, David, 38, 80, 172, 215, 258
Mercer, Vicki, 206
Mesquita, Rickson C., 188
Meulenbroek, Peter, 119
Meydan, Anogue, 215
Meyer, Philippe, 81
Meyling, Christiaan Gmelig, 104, 105, 136
Mez, Jesse, 233
Meza, Faith, 221
Mhlakwaphalwa, Tembeka, 183
Migeot, Anaïs, 46
Miles, Marlie, 183
Miles, Shannon, 15
Miller, Carlin, 223
Miller, Victoria, 177
Mirzazada, Sofia, 174
Mitchell, Jade, 127, 236
Mlandu, Nwabisa, 183
Mochizuki, George, 50, 101, 208
Mockler, David, 154
Modat, Marc, 171
Mohamed, Abdalla, 172
Mohammadian, Mehrbod, 38, 79, 258
Moliner, Belén, 65, 67
Mollnes, Tom, 258
Molteni, Erika, 171
Monahan, Kathleen, 247
Monetta, Laura, 166
Mononen, Malla, 38, 79
Monroe, Derek, 53
Montagliani, Amanda, 114
Montelpare, William, 212
Montgomery, Erin, 222, 245
Monti, Martin, 172, 218, 219
Moore, Marguerite, 214
Moore, Whitney, 41
Moran, Becky, 224
Moran, Catríona, 45, 46, 179
Moran, Tim, 68
Møretrø, Viljar, 190
Morgan, Angela, 227
Morganti-Kossman, Cristina, 188
Morris, Amanda, 121
Morris, Meg, 23
Morrissey, Marquise M., 224
Morrow, Emily L., 19, 48, 127, 187, 201, 238
Mortera, Marianne, 9
Moss, Hilary, 192
Moulavi-Ardakani, Reza, 188
Mozel, Anne, 8
Mozolic, Jennifer, 73
Mrazik, Martin, 198
Muehlmann, Marc, 256
Muhamad, Nor Asiah, 39
Mukkamala, Sridevi, 25
Mulero, Mélanie, 82
Mullen, Christine, 107, 110, 113, 121
Murphy, Deirdre, 150
Murphy, Matthew, 114
Murphy, Sean, 223, 247
Murray, Alena, 31
Murray, Jade, 37
Murray, Laura, 249, 251
Muscat, Christine, 227
Mutlu, Bilge, 50, 121, 166, 238, 246
N
Naboulsi, Edouard, 40
Naccache, Lionel, 215
Naci, Lorina, 175
Næss-Schmidt, Erhard T., 180
Næss-Smith, Erhard Trillingsgaard, 67
Nagele, Drew, 178
Nakase-Richardson, Risa, 216
Nalder, Emily, 29, 85, 190
Narayanan, Ajit, 124
Nardulli, Rebecca, 216
Navarro, María Dolores, 64, 65, 67, 168
Neary, J. Patrick, 207
Neill, Matthew, 194
Nejadnik, Bijan, 44
Nejst, Camilla Hojgaard, 259
Nelson, Audrey, 128
Nelson, Breanna, 239
Nelson, Lindsay, 95
Nesbitt, Ruth, 177
Neumann, Dawn, 98, 252
Newcombe, Virginia, 38, 80, 172, 258
Newsome, Mary, 16, 107, 110, 113, 121, 172
Nguyen, Lily, 145
Nguyen, Sylvia, 37
Ni, Pengsheng, 216
Nichol, Alistair, 142
Nicol, Blake, 186
Nielse, Jørgen Feldbæk, 160
Nielsen, Annesofie Ishøy, 155
Nielsen, Jørgen Feldbæk, 60, 61, 67, 142, 180
Nielsen, Mandy, 31, 132, 133
Niemeier, Janet, 113
Nishat, Eman, 245
Nitzpon, Hanno, 256
Noah Silverberg, 67
Noé, Enrique, 64, 66, 67, 168, 213
Nolan, Ciara, 145
Nolan, Ciarán, 150
Noorbakhsh, Donna, 26
Nordenmark, Tonje Haug, 199
Norman, Alyson, 82, 83, 100
Normand, Emmanuelle, 110
Norton, Loretta, 188, 202
Norup, Anne, 148, 155
Nouvet, Elysee, 249
Novack, Thomas, 21, 253
Novi, Sergio, 188
Nowak, Andrew, 38
Nybo, Taina, 83
Nyhorf-Young, Joyce, 238
O
O’Brien, Katherine, 12
O’Brien, Katy, 23, 108, 109
Ochoa, Christa, 25, 205
Öckl, Patrick, 188
O’Connell, Brendan, 141
O’Connell, Karen, 149
O’Connor, Hugh, 12
O’Connor, Rebecca, 17, 18, 124, 192
Odgård, Lene, 67
O’Doherty, Sarah, 17
O’Donnell, Donna, 49
O’Donnell, Kate, 176, 220
Oh, Byung-Mo, 63
O’Halloran, Phillip, 208
Ohan, Jeneva, 133
O’Hara, Jodie, 146
Ohayagha, Chimdindu, 123
O’Keeffe, Fiadhnait, 45
Olaya, José, 65
Olsen, Alexander, 21, 135, 172, 192
Olsen, Rikke Katrine Jentoft, 60
Olver, John, 23, 58, 119, 128, 145
O’Neil, Maya, 15
O’Neill, Deirdre, 145
O’Neil-Pirozzi, Therese, 17, 33, 216
Oni, Ibukunoluwa, 254
Orman, Gunes, 2
O’Rourke, Justin, 216
Orr, Romayne, 228
Ortiz, J. Bryce, 223
O’Shaughnessy, Josephine M., 246
Osmond, Martin, 32
Ostrow, Joseph, 216
Ou, Zhining, 15
Ouellet, Marie-Christine, 166, 168
Ourselin, Sebastien, 171
O’Valle, Myrtha, 66, 67
Owen, Adrian M., 175, 188, 202, 215
Ozmen, Mustafa, 220
P
Paasila, Jsephine, 250
Pacheco, Marilyn, 117
Padilla, Victoria-Grace, 221
Pae, Erika, 198
Pallesen, Hanne, 67
Palmfeldt, Johan, 60
Palombo, Daniela, 103, 116
Pan, Tracey, 183
Panda, Rajanikant, 60, 64
Panenka, William, 102, 239
Panico, Francesco, 209
Pankatz, Lara, 256, 257
Pantaléo, Stéphanie, 156
Pantelatos, Rabea, 71, 72
Pape, Theresa, 117
Pape, Theresa Bender, 235
Pappadis, Monique R., 8, 197
Paquette, Guillaume, 169
Pasipanodya, Elizabeth, 113
Pasquina, Paul, 8
Pasquini, Katie, 241
Pasternak, Ofer, 256
Patel, Nirav N., 48, 201, 202
Patil, Vijaya, 117
Patsakos, Eleni, 56, 57, 161
Patterson, Alyssa, 221
Patterson, David, 218, 219
Patterson, Freyr, 131
Paul, Harriet, 40
Paul, Mini Mary, 149, 225
Pedersen, Asger Roer, 60
Pedersen, Sedsel Kristine Stage, 67
Pedlow, Katy, 79
Peeters, Frenk, 146
Pei, Yalian, 23, 108, 109
Pelo, Ryan, 121
Perdrieau, Valérie, 71, 110
Perera, Robert, 252
Perez, Olinda Habib, 222
Pérez-Rodríguez, Marta, 92, 93, 94
Perkins, Susan, 8
Perrin, Fabien, 40, 90
Perrin, Paul, 113, 123
Persaud, Trevor, 114
Pesci, Blandine, 46
Philippeau, Lise Pronesti, 199
Phillips, Christophe, 64
Phung, Vy, 198
Phyland, Ruby, 128
Pichon, Bertrand, 199
Pickard, John, 215
Picon, Edwina L., 102, 103, 116
Picq, Christine, 199
Picq, Jean-Luc, 156
Pieper, Andrew, 56
Pigot, Hélène, 169, 173, 190
Pilli, Kavya, 78
Pinto, Shanti, 210
Piotto, Victor, 10
Pirnay, Laurence, 120
Pischke, Søren, 258
Pituch, Evelina, 29
Plessis, Sané du, 254
Pogoda, Terri, 15
Pogue, Jacqueline, 79
Poncet, Frédérique, 48, 206
Ponds, Rudolf, 143
Ponsford, Jennie, 21, 37, 46, 56, 61, 62, 119, 128, 135, 161, 172, 234, 235
Ponsford, Michael, 128
Pontee, Nicole, 4
Porfido, Tara, 99
Posti, Jussi, 38, 79, 258
Poulin, Valérie, 29, 166
Pounch, Jillian, 111, 155
Poveda, Blanca, 162
Powell, Lisa, 181
Poznansky, Mark, 28
Pradat-Diehl, Pascale, 46
Pradhan, Sujata, 109, 130
Prendiville, Kate, 149
Presson, Angela, 15
Preszler, Jonathan, 95
Price, Taylor, 242
Provvidenza, Christine, 114, 212, 223
Pruyser, Ariel, 233
Ptito, Alain, 173, 185
Pugh, Mary Jo, 15, 16, 220
Pulido-Pascual, José Carlos, 93
Purser, Sam, 76
Putrino, David, 135
Putukian, Margot, 8
Pyles, Richard B., 58
Q
Quilico, Enrico, 167
Quinn, Catherine, 32
R
Rabinowitz, Amanda, 33
Rackley, Payton, 253
Rajaram, Alysha, 114
Rajaratnam, Shantha, 37
Rakers, Sandra E., 65, 85, 100, 152, 224
Ramos, Sara Da Silva, 40
Ramsey, Crystal, 206, 213, 217
Rana, Sabhya, 211
Randolph, Kathleen, 58
Rapport, Lisa, 21
Rask, Charlotte Ulrikka, 180
Rasmussen, Mari S., 76, 143
Rathi, Yogesh, 256
Rauch, Robert, 79
Raukola-Lindblom, Marjaana, 36, 139
Rauscher, Alexander, 239
Rauwenhoff, Johanne, 146
Rawls, Erica, 73
Read, Emma, 107, 110, 113, 121
Redell, Curtis, 126
Reed, Nick, 32, 163, 164, 181, 183, 194, 212, 228, 230, 231, 232, 249
Reed, William R., 9
Reeh, Colton, 12
Regnier, Amandine, 120
Rego, Karina, 202
Rehman, Rida, 152
Reijbroek, Mariëlle, 20
Reilly, Laura, 145
Reiman, Eric M., 257
Reistetter, Timothy, 197
Reitz-Krueger, Cristina, 73
Reme, Silje Endresen, 137
Rennie, Amy, 117
Renoult, Louis, 221
Rentinck, I. R., 104
Rentinck, Ingrid, 105, 136
Rhea, Christopher, 53
Richardson, Denyse, 238
Richardson, Risa, 51
Rijnen, Sophie, 18, 20, 106
Rike, Per-Ola, 63, 137
Ringshaw, Jessica, 183
Rioux, Mathilde, 102
Ripat, Jacquie, 48
Ripley, David, 117
Risen, Sarah, 2
Risnes, Kari, 84
Riu, Béatrice, 40, 90
Rø, Torstein Baade, 84
Ro, Young Sun, 31, 63, 125
Robert, Hélène, 199
Roberts, Samantha, 50
Robinson-Bert, Krystal, 1
Roby, Tricia, 8
Rodríguez, Clara, 67
Røe, Cecilie, 66, 72, 76, 99, 158, 161, 184, 196, 199
Rogers, Alicia A., 52
Rogers, Laura, 253
Rohaut, Benjamin, 215
Rohrer-Baumgartner, Nina, 158, 184, 190
Romero, Kenia, 73
Root, Jeremy, 95
Rosario, Emily, 218, 219
Rose, Sean, 157, 176
Roselli, Francesco, 152, 188, 189
Rosen, Gunnar, 138
Rosenow, Joshua, 117
Rossner, Stephan, 138
Rotenberg, Shlomit, 89, 90
Roth, Elliott, 117
Roussel, Cindy, 199
Rowe, Rachel, 223
Rucobo, Sara Chaparro, 54
Ruet, Alexis, 80, 81
Rull, Rudolph, 22
Rushworth, Nick, 34, 78
Russell, Hilary, 107, 110, 113, 121
Russell, Trevor, 131
Ruttan, Lesley, 101, 211
Ryan, Jennifer, 153, 174
Ryan, John, 141
Ryu, Hyun ho, 11
S
Saarinen, Mari, 111
Saber, Heba Gamal, 5
Sagliano, Laura, 209
Saksvik, Simen Berg, 192
Sala, Arianna, 60, 64, 234
Salazar, Ana Paula, 88, 89, 90
Saluja, Rajeet, 185
Saluja, Rajeet Singh, 173
Samuels, Reese, 183
Sanchez, Jean-Charles, 38, 80, 258
Sandel, Elizabeth, 251
Sander, Angelle, 8, 33, 98
Sanders, William, 215, 216
Sandhaug, Maria, 190
Sandmo, Stian Bahr, 256
Sandrød, Oddrun, 71, 72
Sandroni, Claudio, 209
Santos, Joao-Paulo Lima, 101
Sanz, Leandro R. D., 60, 234
Sarazin, Eléonore, 168
Sarton, Benjamine, 40, 90
Sasson, Nicole, 9
Satyen, Lata, 34
Saverino, Cristina, 211
Savundra, Peter, 226
Savundranayagam, Marie, 251
Sawyer, Simon, 77
Scaglia, Fabio, 151
Scatozza, Rossella, 151
Scheibel, Randall, 15, 16
Scheinberg, Adam, 43, 78, 79
Scheul, Stephan, 117
Schiattone, Sara, 84
Schiff, Nicholas, 215
Schindele, Andreas, 64
Schmidt, Julia, 88, 89
Schnakers, Caroline, 124, 213, 218, 219
Schneider, Alexandra L., 95
Schneider, Kathryn J., 181, 194
Schröder, Andreas, 180
Schuhmacher, Luisa S., 257
Schultz, Sandy R., 188
Schwab, Didier, 82
Schwarb, Hillary, 187, 201, 202
Schwartz, Neil E., 44
Scott, Fransesca, 8
Scratch, Shannon E., 114, 122, 203, 212, 223, 227, 230, 231, 232, 236, 245, 249
Sedzro, Mawukoenya Theresa, 249, 251
Seenivasan, Srija, 195
Seer, Caroline, 256
Seifert, Jack, 112
Selte, Atakan, 234
Semmel, Eric, 103
Semple, Bridgette, 188
Sepehrband, Farshid, 256
Sergeyenko, Yevgeniya, 35
Seu, Alika, 124
Sevigny, Mitch, 98
Shah, Alok, 112
Shaltoni, Hashem, 197
Shan, Xiang, 114
Sharma, Pushpa, 127
Sharp, David, 150, 172
Shaw, Gerry, 211
Sheffield-Moore, Melinda, 58
Sheldrake, Elena, 230, 232
Shenton, Martha E., 256, 257
Shepherd, Heather A., 181, 183, 194
Sherer, Mark, 216
Sherrington, Catherine, 78
Shi, Junxin, 176
Shi, Shuyuan, 102
Shidolfsky, Kara, 52
Shih, Hui-Ting, 205
Shill, Isla J., 181, 198, 217, 241, 242
Shin, Min-Kyoo, 56
Shin, Sang Do, 31, 125
Shore, Josh, 231, 249
Shwed, Alanna, 77, 186
Sicard, Veronik, 163, 164
Siegert, Richard, 124
Silva, Stein, 40, 90
Silverberg, Noah D., 102, 103, 116
Simard, Pascale, 210
Simpson, Grahame, 7, 78, 92, 130, 134, 237, 250
Singer, Barby, 123
Singer, Timothy G., 2
Singh, Jyotpal, 207
Singh, Kris, 126
Sinnott, Natasha, 20
Sirbulescu, Ruxandra, 28
Sitt, Jacobo, 215
Sixsmith, Jane, 86
Skandsen, Toril, 71, 72, 192, 258
Skarbø, Anne-Britt, 84
Skovlund, Eva, 84
Slattery, Catherine, 149
Slomine, Beth, 189
Slooter, Arjen, 86
Smevik, Hanne, 172
Smith, Andra, 163, 164
Smith, Aynsley, 229
Smrcka, Martin, 11
Smyth, Bridget, 32
Snapp, Erin, 41
Snekkevika, Hildegun, 137–138
Søberg, Helene Lundgaard, 138, 143
Sochen, Nir, 256
Soddu, Andrea, 215
Soendergaard, Pernille Langer, 148
Song, Sang Hoon, 63
Sorita, Eric, 206
Sorteberg, Angelika, 199
Soto, Graycie, 253
Souza, Nicola de, 99
Sperry, Dee, 248
Sperry, Deidre, 241
Spielman, Lisa, 233
Spikman, Jacoba M., 65, 85, 137, 224
Spikman, Joke, 21, 152
Spitz, Gershon, 37, 172
Staccioli, Susanna, 147
Staines, Anthony, 176, 220
Stamatakis, Emmanuel, 214
Stanfill, Ansley, 9
Stang, Antonia, 157
Stanley, Rachel, 157, 176
Stapleton, Tadhg, 145
Staquet, Cécile, 87
Steel, Joanne, 131
Steinberg, Gary K., 44
Stella, Julian, 34
Stemper, Brian, 112
Stenberg, Jonas, 71, 72
Stenbro, Laura Westh, 142
Sterling, Ally, 215, 216
Stern, Robert A., 257
Stevens, Dale, 185
Stiekema, Annemarie, 18
Stockley, Cassandra, 89
Stojanovski, Sonja, 245
Strand-Saugnes, Anine Pernille, 190
Stranges, Tori N., 77
Straudi, Sofia, 151
Strazzer, Sandra, 171
Stuart, Michael, 229
Stubberud, Jan, 84
Stubbs, Jacob, 239
Su, Wayne, 239
Summers, Aly, 238
Suskauer, Stacy, 189
Susmarski, Adam, 8
Sutherland, Edwina, 123
Svendsen, Edel, 190
Svendsen, Edel Jannecke, 158, 184
Svingos, Adrian, 189
Swaine, Bonnie, 28, 88, 89, 167
Swank, Chad, 25, 26, 153, 205
Sweet, Shane, 167
Swinnen, Stephan P., 256
Szymkowicz, Emilie, 60
T
Tahry, Riëm El, 141
Takala, Riikka, 80, 258
Tallus, Jussi, 80, 258
Tam, Alan, 211
Tamnes, Christian, 24
Tanguay, Annick, 221
Tapin, Marjolaine, 89
Tas, Jeanette, 148
Tassini, Carolyn, 204
Tate, David F., 15, 110, 172, 220
Taylor, Ian, 79
Taylor, Karene, 165
Taylor, Taryn, 244
Taylor-Goh, Sylvia, 225, 226
Teasell, Robert, 56, 57, 161
Teel, Elizabeth, 205
Tefertiller, Candy, 21
Tekemetieu, Armel Ayimdji, 169
Temkin, Nancy, 109, 130
Tendolkar, Indira, 106
Tenovuo, Olli, 38, 80, 111, 139, 258
Terneusen, Anneke, 143
Teti, Selina, 251
Thastum, Mille Moeller, 180
Thatsum, Mille Møller, 67
Thayn, Dayna, 107, 110, 113, 121
Theodiraki, Eleni, 262
Thibault, Geneviève, 85
Thibaut, Aurore, 60, 64, 84, 120, 141, 213, 215, 234
Thomas, Amber, 216
Thomas, Danny, 95
Thomas, Matt, 106
Thompson, Karla, 9
Thompson, Paul, 172
Thomsen, Cynthia, 9, 33
Thornton, Allen, 239
Thuss, Nikki, 152
Tiedemann, Anne, 78
Tlustos, Sarah, 239
Tobin, Anna, 69
Tobin, Katy, 159
Todd, Rebecca, 103, 116
Togher, Leanne, 56
Toma, Catalina L., 121, 238, 246
Tonks, James, 102
Topping, Megan, 59
Torchia, Kristen, 174
Tornås, Sveinung, 21, 135
Tornatore, Giovanna, 131
Tornero-Almendros, Pedro, 93
Toure, Hanna, 81
Towle, Cara, 129
Trammell, Molly, 205
Tran, Joanna, 37
Trayner, Penny, 227
Trbovich, Alicia, 95, 101
Trender, William, 150
Trevena-Peters, Jessica, 56, 161
Tripodis, Yorghos, 256, 257
Troeung, Lakkhina, 126, 131
Trojano, Luigi, 209, 213
Trone, Daniel, 22
Troyanskaya, Maya, 15
Truong, Johnny, 34
Tsao, Jack, 9
Turcotte, Kate, 194, 244
Turcotte, Samuel, 210
Turkstra, Jamila, 244
Turkstra, Lyn S., 50, 56, 121, 166, 238, 244, 246
Turner, Gary, 185
Turner, Rose, 95
Turner, Sarah, 40
Turpin, Merrill, 77
Tuz-Zahra, Fatima, 257
Tweedy, Sean, 78
Twomey, Deirdre, 45
Twomey, Valerie, 18, 177, 179, 180
Tyas, Rosanne, 124
U
Ugart, Patricia, 67
Urban, Randall J., 58
V
Vaccaro, Monica, 178, 198
Valaas, Lars-Johan, 143
Valente, Mélanie, 215
Valera, Eve, 244
Vallat-Azouvi, Claire, 80, 81, 140, 156
Vallée, Catherine, 210
van den Berg, Carla, 183
van den Broek, Brenda, 18, 20
van den Hof, Thomas R., 96
van der Horn, Harm, 137
van der Horst, Iwan, 148
van der Naalt, Joukje, 137, 152
van Donkelaar, Paul, 7, 77, 186
van Gils, Mark, 258
van Goethem, Sébastien, 60, 87
van Het Hoog, Béatrice, 28
van Heugten, Caroline, 18, 86, 143, 146, 148
van Ierssel, Jacqueline Josee, 74
Vargas, Tiffanie, 113
Vasic, Stefan, 113
Vassallo, Gabrielle, 78
Vaughan, Christopher, 248
Vazirani, Aashna, 131
Vazquez-Rosa, Edwin, 56
Veeramuthu, Vigneswaran, 213
Velazquez, Angela, 215
Velez, Carmen, 14, 107, 110, 113, 121
Velikonja, Diana, 56, 161
Venkatesan, Umesh, 33, 240
Verdugo, Miguel Ángel, 170, 184
Verhoeks, Carmen, 106
Versace, Amelia, 101
Verschuren, O. V., 104
Verschuren, Olaf, 105, 136
Vertinsky, Alexandra, 239
Vervoordt, Samantha, 172
Verwijk, Esmée, 86
Vešligaj-Damiš, Jasna, 96
Victor, Jonathan, 215
Vik, Anne, 71, 72, 258
Vikane, Eirik, 169
Villain, Marie, 46
Villarino, Pablo, 67
Viola, Nicole, 178
Visser-Meily, Johanna, 86
Vitello, Marie, 141
Vogler, Jessica, 31
Volmrich, Alyssa, 19, 20
von Seth, Charlotta, 159
von Soest, Tilmann, 24
Vora, Ariana, 9
Vora, Isha, 215
Vosinek, Teja, 96
Vox, Ford, 35
Vrbica, Kamil, 11
Vrosgou, Athina, 215
Vyas, Ayush, 56
W
Wade, Benjamin, 14
Wade, Shari L., 158, 184, 212
Waldron, Brian, 176, 220
Walker, Thomas, 52
Walker, William, 15, 16, 21
Wallace, Eugene, 149
Wallace, Tracey, 68, 97, 108, 109, 171
Walsh, Anthony, 77
Walsh, Elyse, 117
Walsh, Jane, 53
Walsh, Kim, 236
Walsh, Kimberly, 48
Walterfang, Mark, 128
Wanderley, Lissa Marque, 206
Wang, Rosalie H., 29
Wang, Ryan, 240
Wang, YongSheng, 211
Ward, Marcia, 3
Wassef, Ghada, 5
Watanabe, Thomas, 21
Waters, Abigail, 215, 216
Watter, Kerrin, 31, 132, 133
Weaver, Jerre, 130
Wegener, Erin, 124
Wehling, Eike, 169
Weill-Chounlamountry, Agnès, 46, 199
Weintraub, Alan H., 44
Welch-West, Penny, 56
Wen, Pey-Shan, 9
Weppner, Justin, 36, 41, 124
West, Stephen W., 217, 241, 242
Westerhof-Evers, H. J., 224
Westlye, Lars, 172
Westmacott, Robyn, 42
Wetherell, Aura, 244
Wexler, Tamara, 58
Whalen, Michael, 28
Wheeler, Anne, 230, 232, 245
Wheeler, Krista, 176
Whiffin, Charlotte, 82
Whiteneck, Gale, 33
Whiteside, Clair, 89
Whiting, Diane, 130, 134
Whyte, John, 109
Wiegand, Tim L. T., 256, 257
Wiegersma, Marije, 197
Wiersma, Jan, 197, 205
Wiest, Matheus, 93
Wilcock, Ruth, 89, 196, 212
Wilde, Elisabeth A., 15, 16, 107, 110, 113, 121, 172, 220
Wilkinson, Shawn, 167
Willer, Barry, 38, 160
Williams, Gavin, 23, 78, 123, 145
Williams, Huw, 27, 68
Williams, Janet, 230
Williams, Richelle M., 107, 154
Williams, Steven, 183
Wilmore, Rachelle, 237
Wilson, Alison, 254
Wilson, Alyssia, 42
Wilson, Fiona, 107, 141, 154
Wilson, Katherine, 228
Wilson, Riis, 253
Windle, John, 208, 262
Winkens, Ieke, 143
Winkler, Di, 59
Wiseman-Hakes, Catherine, 56, 161
Wisinger, Amanda, 117
Wojtowicz, Magdalena, 50, 185
Wolfert, Stephanie, 240
Wolffbrandt, Mia Moth, 148
Wong, Dana, 37
Wong, Vicki, 203, 204, 205
Woo, Jean, 12
Woods, Nancy, 1
Wray, Melissa, 36, 41
Wright, Brennan, 16
Wright, F. Virginia, 249
Wright, Sarah T., 9
Wright, Traver J., 58
Wright, Virginia, 153, 174, 231
Wyse, Jason, 141
X
Xia, Bridget, 113
Y
Yamaki, Tomohiro, 13
Yan, Xiang-Dong, 95
Yang, Melissa, 204
Yaroslavtseva, Olga, 57
Yasuhara, Takao, 44
Yeates, Keith Owen, 74, 157, 163, 164, 181, 183, 212
Yelden, Kudret, 124
Yeomans, Caithriona, 107, 136, 154
Yeow Leng, Tan, 3
Yhang, Eukyung, 256
Yin, Ziyang, 114
Ymer, Lucy, 37
Yoon, Hanna, 63
Young, Jamie, 204
Yu, Youngmin, 56
Z
Zafonte, Ross, 35, 113, 172
Zarshenas, Sareh, 89, 90, 190
Zasler, Nathan, 213
Zeineh, Michael, 191
Zemek, Roger, 32, 74, 163, 164
Zettenberg, Henrik, 38
Zetterberg, Henrik, 80, 258
Zhang, Bei, 12
Zhang, Cherri, 74
Zhang, Chong, 16
Zhang, Jin, 189
Zhang, Rong, 210
Zhang, Yue, 21, 253
Zhao, George, 238
Zheng, Zhong Sheng, 218
Zhou, Chuanlin, 153
Ziejewski, Mariusz, 13
Zurawski, Sandy, 26
Notes
* Numbers in Index indicate the page number for each associated abstract in this supplement.